306004449-5-21-2026-22-AS-AORZ-DURUJX-20260605153812

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004449
Report Date: 05/21/2026
Date Signed: 05/21/2026 12:24:49 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
11/13/2025 and conducted by Evaluator Samer Haddadin

COMPLAINT CONTROL NUMBER: 22-AS-20251113101510

FACILITY NAME:	MAC RESIDENTIAL HOME		FACILITY NUMBER:	306004449
ADMINISTRATOR:	EVELINA SCHAEFER		FACILITY TYPE:	735
ADDRESS:	705 N. GILBERT STREET		TELEPHONE:	(714) 995-4131
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92801
CAPACITY:	6	CENSUS: 2	DATE:	05/21/2026
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Ronald Manald		TIME COMPLETED:	04:04 PM

ALLEGATION(S):

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Resident sustained a fall due to Neglect/lack of care resulting in serious injury.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced visit to the facility to deliver findings regarding the above-mentioned allegation. Upon arrival, LPA was greeted and granted entry by Licensee Ronald Manalad. It was alleged a Resident sustained a fall due to Neglect/lack of care resulting in serious injury. The investigation included review of the Service Request, Special Incident Reports, facility records, medical records, and 911 records. Three facility staff interviews were conducted, and one interview was conducted with C1's responsible party.
The investigation found the following:
Client 1 (C1) was diagnosed with developmental delay, psychotic disorder, impulse control disorder, and schizophrenia. Records and interviews indicated C1 had a known history of falls and unsteady gait, and C1 used assistive devices to ambulate. C1 required assistance and supervision based on C1's functional limitations and fall risk dated December 9th, 2025
The investigation found the following:{***CONTINUE 9099C***}

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2026

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 4

Control Number 22-AS-20251113101510

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: MAC RESIDENTIAL HOME	FACILITY NUMBER: 306004449
	VISIT DATE: 05/21/2026

NARRATIVE

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Records obtained documented that C1 had a history of falls, sustaining at least four known falls between July 2024 through October 2025. Records did not show that the facility completed a timely reappraisal nor implemented updated fall-risk interventions after each fall. After C1’s fall in October 2025, the facility and C1’s service coordinator discussed possible fall-risk interventions. These interventions included the use of a walker, wheelchair, helmet, physical therapy referral, fall-risk assessment, and staff supervision when C1 used the restroom or changed clothing. However, interviews with three facility staff members and one service coordinator indicated that these interventions had not been fully implemented prior to C1’s fall on November 5, 2025. Interviews with staff report that two of the four clients require full assistance with activities of daily living. Despite this, facility staff also reported that the night shift was staffed with one caregiver because clients were generally expected to be asleep during the night despite C1 requiring supervision when using the restroom. In addition, the facility’s night-check practice was described as periodic checks throughout the night; however, the Administrator stated that staff did not maintain a physical log documenting those checks.
During the night of November 5th, 2025, Direct Support Professional (DSP1) was the only staff on duty and was responsible for overnight monitoring and periodic checks. DSP1 reported they were in the restroom when they heard C1 calling for help and found C1 lying on the bathroom floor with C1's walker/rollator nearby. DSP1 stated C1 had gone to the restroom independently and had not requested assistance before entering the restroom. DSP1 placed a pillow under C1's neck for support and called 911. C1 was transported to the hospital where they were admitted.
Per hospital medical records, C1 sustained blunt trauma, spinal injury, and a fracture, and required intubation due to acute respiratory failure requiring surgery and ongoing intensive medical care. C1 was unable to move all four extremities. {****CONTINUE 9099C***}

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 22-AS-20251113101510

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: MAC RESIDENTIAL HOME	FACILITY NUMBER: 306004449
	VISIT DATE: 05/21/2026

NARRATIVE

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Interviews with facility administrators and staff revealed that the facility was aware of C1's fall history and escalating fall risk before the November 5th, 2025 incident. The administrator stated that after C1's September 2025 fall, facility staff instructed C1 to ask for assistance when using the restroom or changing clothing, and this was corroborated by the service coordinator interview and post-fall discussions regarding supervision. However, the evidence showed C1 was able to enter the restroom independently during the night because the facility continued to rely on C1 to request assistance and assigned one caregiver during the night shift. Had the facility had more than one staff on duty, staff would have been available to assist C1 to the restroom when DSP1 was taking a bathroom break. The administrator also stated that, prior to the November 2025 fall, the facility did not have an emergency plan for resident falls other than calling 911. Training regarding changes in condition and fall-risk procedures was not completed until December 2025, after C1's serious injury.
Based on the record review and interviews, the facility failed to provide supervision and fall-prevention follow-up that corresponded with C1's known needs, fall history, and increased risk of injury.
Based on the preponderance of evidence, the allegation Resident sustained a fall due to Neglect/lack of care resulting in serious injury is substantiated. The following is being cited per Title 22, Division 6 of the California Code of Regulations.
A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49(f).
An exit interview was conducted, and copies of this report, LIC 9099-D, Appeal Rights, Civil Penalty Assessment (LIC 421IM), and LIC 811 (Confidential Names) were provided to the facility representative at the conclusion of the visit.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 22-AS-20251113101510

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: MAC RESIDENTIAL HOME	FACILITY NUMBER: 306004449
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/21/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/22/2026 Section Cited CCR 80078(a)	1 2 3 4 5 6 7	Section 80078(a) - Responsibility for Providing Care and Supervision: The licensee shall provide care and supervision as necessary to meet the client's needs.This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee will conduct staff training for Care and Supervision of clients by reviewing section code 80078(a) and document the staff training and submit the proof to LPA by POC due date
	8 9 10 11 12 13 14	Based on record review and interviews, the facility failed to provide care and supervision as necessary to meet C1's needs. C1 had a known history of falls and unsteady gait, and required supervision while toileting or changing. On November 5th, 2025, C1 sustained an unwitnessed fall while using the restroom independently that resulted in spinal injuries, quadriplegia, intubation, ventilator dependence, and inability to move C1's extremities. This failure posed an immediate health and safety risk to clients in care.	8 9 10 11 12 13 14
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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.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2026

LIC9099 (FAS) - (06/04)

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