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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004680
Report Date: 11/19/2025
Date Signed: 11/19/2025 02:24:06 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
11/17/2025 and conducted by Evaluator Jessica Cho
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20251117095450
FACILITY NAME:F & G CARE HOMEFACILITY NUMBER:
306004680
ADMINISTRATOR:AUGUSTUS A. TORRESFACILITY TYPE:
735
ADDRESS:24672 RHEA DRIVETELEPHONE:
(949) 273-5022
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 4DATE:
11/19/2025
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Gilbert Roque- Care StaffTIME COMPLETED:
02:40 PM
ALLEGATION(S):
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Facility did not follow the plan of operation.
Facility did not have adequate staffing ratios.
Facility did not maintain personnel records.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jessica Cho made an unannounced visit for the purpose of initiating the complaint investigation into the above allegations. LPA was greeted and granted entry by Care Staff (CS) Gilbert Roque and explained the reason for the visit. Administrator (Admin) Augustus Torres was also advised of the visit by telephone at 10:04am. During the course of the investigation, LPA interviewed two staff and reviewed and obtained copies of the following records: Personnel Report, Face Sheet, Indivdiual Program Plan (IPPs) for all clients, regional center Annual Findings, staff training records (DSP I/II & Continuing Education hours, & CPR/first aid certifications), administrators' certificates, and sign in and out form.

The investigation is as follows: Regarding the allegation, Facility did not follow the plan of operation, it is alleged that the staff did not complete the required training. In review of staff records, one out of four staff did not meet the training requirements. Staff #4 (S4) was employed in 2020.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2025
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-20251117095450
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: F & G CARE HOME
FACILITY NUMBER: 306004680
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/28/2025
Section Cited
CCR
80022(k)
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80022 Plan of Operation (k) The facility shall operate in accordance with the terms specified in the Plan of Operation and may be cited for not doing so.

This requirement was not met as evidenced by:
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Administrator stated that the plan of operation will be reviewed and a written Acknowledgement of Understanding of the said deficiency will be submtited to LPA by POC due date.
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Based on record review, facility did not follow their plan of operation as three out of four staff did not meet the training requirements which posed a potential Health, Safety, and/or Personal Rights risk to persons in care.
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Type B
11/28/2025
Section Cited
CCR
85065.5(a)(1)
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85065.5 Day Staff- Client Ratio (a) (1) For Regional Center clients, staffing shall be maintained as specified by the Regional Center but no less than one direct care staff to three such clients.

This requirement was not met as evidenced by:
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Administrator stated that they will employ a second staff effective immediately, submit an updated Personnel Report to LPA by POC due date.
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Based on observation, interviews, and record review, facility did not ensure that one out of four clients is receiving 1:1 care and supervision per the IPP which poses a potential Health, Safety, and/or Personal Rights risk 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.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 22-AS-20251117095450
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: F & G CARE HOME
FACILITY NUMBER: 306004680
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/28/2025
Section Cited
CCR
80066(a)
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80066 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee.

This requirement was not met as evidenced by:
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Administrator stated that sign in and out form will be implemented for all staff effective today and will provide proof to LPA by POC due date.
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Based on interview and record review, facility did not maintain sign in/out records for three out of four staff which poses a potential Health, Safety, and/or Personal Rights risk 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.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 22-AS-20251117095450
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: F & G CARE HOME
FACILITY NUMBER: 306004680
VISIT DATE: 11/19/2025
NARRATIVE
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Based on the review of records, S4 completed the first part of training on March 29, 2017, second training on October 17, 2025, and the annual training on August 10, 2025. The Program Design under section Staff Qualifications indicate that staff will comply with Title 22 Regulations 80065 Personnel Requirements which requires staff are given on-the-job training. The record review revealed that S4 did not meet the training for a period of approximately seven years. Additionally, in review of the CPR/First aid training certificates, two out of the four staff did not meet the requirement. Staff #2 (S2) was without a certificate between January 2024 to March 22, 2024 and March 10, 2021 to February 20, 2023 for Staff #3 (S3). As of today's date, all staff maintain current CPR/First Aid certificates.

It is alleged that the facility did not have adequate staffing ratios. The census is four per review of client files. In review of client records, one out of four clients require 1:1 supervision as noted on page 14 of the IPP for Client #1 (C1). It is determined that there should be two staff present which also aligns with the Title 22 regulation 85065.5 which indicates that "staffing shall be maintained as specified by the Regional Center but no less than one direct care staff to three such clients."

Regarding the allegation, facility did not maintain personnel records, it is alleged that the staff sign in/out sheet was not maintained. Two out of the two staff confirmed that the sign in/out sheet was implemented after the annual review with the regional center conducted on August 7, 2025. LPA observed that the first entry began August 8, 2025 for one out of four staff. There were no entries for the remaining three staff which all "personnel records should be maintained by the licensee."

Therefore, based on observation, interviews, and record review, the above allegations are deemed substantiated. Deficiencies are being cited on the attached LIC9099-D.

An exit interview was conducted with Care Staff Gilbert Roque in person and Administrator Augustus Torres by telephone, and a copy of this report including the appeal rights were provided at exit.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4