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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004198
Report Date: 07/24/2026
Date Signed: 07/24/2026 12:02:22 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/06/2025 and conducted by Evaluator Claudia Gutierrez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20251006141004
FACILITY NAME:VERSA-CARE HOME IFACILITY NUMBER:
306004198
ADMINISTRATOR:CHERRY AGUILAFACILITY TYPE:
740
ADDRESS:1576 SPRUCE UNIT ATELEPHONE:
(714) 646-9217
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY:6CENSUS: 3DATE:
07/24/2026
UNANNOUNCEDTIME BEGAN:
10:46 AM
MET WITH:Cherry AguilaTIME COMPLETED:
12:20 PM
ALLEGATION(S):
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Resident developed an unstageable pressure injury due to staff neglect
INVESTIGATION FINDINGS:
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An unannounced complaint investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez regarding the allegation mentioned above. LPA met with Administrator (AD) Cherry Aguila and discussed the purpose of the inspection.

During the course of the investigation interviews were conducted with two facility staff, Resident 1 (R1), and Witness 1 (W1), and a review of R1’s Service Provider’s (SP’s) medical records and Home Health records was conducted, and the following was revealed:

During their interview, two of two staff stated they were initially unaware of R1’s additional pressure injuries, other than the initial injury to their leg caused by a foot brace. Per Staff 1 (S1), R1 communicates with some facial expressions and is dependent on staff for activities of daily living, such as toileting, and showering. S1 stated they were not initially aware that R1 had developed additional pressure injuries and stated they did not know when the injuries developed. (Cont. LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 22-AS-20251006141004
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: VERSA-CARE HOME I
FACILITY NUMBER: 306004198
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/25/2026
Section Cited
CCR
87464(f)(1)
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87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in... Health and Safety Code section 1569.2(c).

This requirement is not met as evidenced by:
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AD stated staff training regarding resident care and supervision will be conducted and a written plan of action, ensuring facility staff will provide basic services to residents, will be provided to LPA via email by POC date.
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Based on staff interviews and record review, the Licensee did not comply with the section cited above as R1 developed two unstageable pressure injuries while in care due to staff neglect, which posed an immediate health, safety, and personal rights risks to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 22-AS-20251006141004
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: VERSA-CARE HOME I
FACILITY NUMBER: 306004198
VISIT DATE: 07/24/2026
NARRATIVE
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Based on the investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. Deficiencies are being cited per Title 22 Division 6 of the California Code of regulations (see LIC9099-D), and an Immediate $500 Civil Penalty is being assessed (see LIC421IM). Additional Civil Penalty is pending determination as per Health & Safety Code 1569.49(f).

An exit interview was conducted, and a copy of this report and appeal rights was provided at the end of inspection.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20251006141004
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: VERSA-CARE HOME I
FACILITY NUMBER: 306004198
VISIT DATE: 07/24/2026
NARRATIVE
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Per S1, they only saw a line on R1’s backside and stated although they did not document, they would reposition R1 every two hours. During their interview, S2 stated R1 had been receiving home health services and stated they did not know why these services were terminated and had contacted the Home Health agency and had been informed all visits were completed, and they would have to contact R1’s SP. Per S2, R1 was without home health for approximately three weeks (September 11, 2025 through September 25, 2025), however, S2 stated several Social Workers (SWs) would come to visit and in September 2025, R1 did not have any wounds. S2 stated the only issue had been with R1’s feet and the podiatrist prescribed “booties” which caused R1 to sustain a crease on their leg. Per S2, the crease was not open but was “black and blue.” S2 stated they had photographed it, however, was unable to provide the Department with the photograph. S2 stated that by the beginning of October 2025, the wound became a laceration which did open, and a wound nurse began treating it on September 29, 2026. Per S2, they were instructed by the nurse not to agitate or treat the injury. S2 stated they provided a sponge bath to R1 every week and they made sure the laceration dressing was kept dry and that the injury was always bandaged, and neither S2, nor other facility staff visibly saw the injury. S2 stated they had no reason to think R1 was in any immediate danger because R1 was eating well, and they saw no grimace regarding the crease wound.

During their interview, W1, a Social Worker, stated they conducted a visit on September 29, 2025, to the facility and observed a blackened sore on R1’s right heel and noted a cotton wrap around R1’s left calf. Per W1, S1 stated R1 had “tiny, small sores” on their back and a worsening sore on their heel and reported that a podiatrist had recommended a heel protector, which was applied on September 16, 2025, however, by September 17, 2025, the heel sore had worsened. Per W1, R1’s SP was not informed of the sores until September 26, 2025, nine days after the initial observation. W1 confirmed that had been a lapse in home health services for approximately three weeks as R1’s SP does not have its own staff to check on R1 weekly, therefore, a SW would conduct a visit periodically, and a home health care nurse would visit two times a month. Per W1, an air mattress was ordered by R1’s SP to alleviate the pressure of the pressure injuries and when they inquired about the low-air-loss mattress and Hoyer lift, which had also been ordered by R1’s SP, S1 informed them the mattress had been returned because R1 "did not like it” and S1 was unsure whether the current Hoyer lift belonged to R1. W1 confirmed that the air loss mattress was transported and delivered on July 2, 2025, and the facility declined to receive it, although they signed for it, and the Hoyer lift had been provided to assist with transfers. Per W1, the Hoyer lift was not utilized as R1 had not been out of bed for two months and stated facility staff have been educated multiple times to inform R1’s SP of health changes. (Cont. LIC9099-C)
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 22-AS-20251006141004
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: VERSA-CARE HOME I
FACILITY NUMBER: 306004198
VISIT DATE: 07/24/2026
NARRATIVE
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Per W1, a second mattress was subsequently ordered and installed a day after it was received, however, R1’s SP was not satisfied with the care being provided and subsequently removed R1 from the facility’s care.

During their interview, R1 was not aware of the day of the week or the time and was unable to confirm or deny allegation and stated they did not have any issues while living at the facility. Per review of medical records, R1 has dementia and is dependent on staff for activities of daily living, such as toileting, bathing, grooming and showering.

A review of Home Health Medical Records for R1 revealed the following: On September 23, 2025, R1 was discharged from home health services due to the end of episode. On September 26, 2025, R1 resumed care after an assessment and was noted to have developed two unstageable pressure injuries. The Home Health Nurse (HHN) conducted an assessment, a skilled observation, interviewed R1, and noted R1 is completely immobile and requires total assistance for all movements. S1 reported prior ecchymosis from foot brace and area appeared worsened due to immobility and continuous pressure. HHN instructed S1 on importance of frequent repositioning and reinforced need to avoid use of tight devices to prevent further injury. On October 2, 2025, it was noted that HHN had instructed and taught R1 on pressure ulcer of right heel, which was unstageable, performed medication reconciliation, and drug regimen review.

Based on review of R1’s records and the facility visitor log, there is no evidence that R1 was seen by a HHN between August 22, 2025, and September 25, 2025. On September 26, 2025, W1 visited R1 and observed the onset of a pressure ulcer on R1’s back. During a subsequent visit on September 29, 2025, S1 informed W1 that R1 had developed small sores on the back and a worsening sore on the heel. S1 stated that a podiatrist had recommended a heel protector, which was applied on September 16, 2025, but S1 observed that the heel sore continued to worsen. A review of the records found no documentation that additional wound care or treatment was provided to R1 until the HHN resumed services on September 27, 2025, after the facility reported R1’s skin condition to R1’s SP on September 26, 2025. HHN continued treating R1’s pressure wounds until October 2, 2025, and noted a stage 3 mid back wound, unstageable right heel and left heel wounds, and deep tissue injuries on left and right lower shins.

R1 was transferred to a Skilled Nursing Facility (SNF) on October 3, 2025. It was noted on the SNF’s records that on admission, R1 had pressure wounds on left shin, left heel, right and left medial thighs, and spine (unstageable). (Cont. LIC9099-C)
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5