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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004689
Report Date: 04/25/2025
Date Signed: 04/25/2025 01:12:20 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
04/11/2025 and conducted by Evaluator Samer Haddadin
COMPLAINT CONTROL NUMBER: 22-AS-20250411093950
FACILITY NAME:JIDDE RESIDENTIAL HOME IIIFACILITY NUMBER:
306004689
ADMINISTRATOR:DEXTER DIZONFACILITY TYPE:
735
ADDRESS:3127 W. TYLER AVENUETELEPHONE:
(714) 828-9637
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY:6CENSUS: DATE:
04/25/2025
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:TIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Facility abandoned client at the hospital
INVESTIGATION FINDINGS:
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On April 24, 2025, Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced visit to this facility to present findings regarding alleged violations. Upon stating the purpose of the visit, LPA Haddadin was greeted by house Manager (HM) Sarah Pinero and granted entry.

During the investigation, LPA Haddadin toured the facility, interviewed staff members and the licensee, and reviewed resident files.

The Regional Center of Orange County (OCRC) referred a prospective client (C1) to this facility, requesting that the Facility Administrator (AD) conduct a pre-admission visit to determine if C1 was a suitable placement. On March 28, 2025, the Administrator visited the client and agreed to accept C1. Subsequently, on April 1, 2025, the facility's House Manager took custody of the client, signing the discharge paperwork from Artesia Palms Post Acute, where C1 had resided previously.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2025
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 3
Control Number 22-AS-20250411093950
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: JIDDE RESIDENTIAL HOME III
FACILITY NUMBER: 306004689
VISIT DATE: 04/25/2025
NARRATIVE
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Regarding the allegation of "Facility abandoned client at the hospital," LPA Haddadin reviewed Client-1's (C1) file, which included the Individual Program Plan (IPP) and the discharge paperwork from Artesia Palms Post Acute. This review confirmed that the facility's House Manager picked up the client on April 1, 2025, with the intention of admitting C1 to the facility. However, during an interview with the House Manager and Care Staff, LPA Haddadin learned that the client was sent to West Anaheim Medical Center via ambulance on April 2, 2025, after complaining of breathing difficulties. No facility staff member accompanied the client to the hospital. On April 3, 2025, hospital staff attempted to contact the facility multiple times via voicemail to arrange for the client's pick-up. By April 15, 2025, the hospital made a final unsuccessful attempt to reach facility staff.

On April 18, 2025, LPA Haddadin interviewed the Administrator, House Manager, and Care Staff of the facility. All individuals informed LPA Haddadin that the client required a higher level of care than the facility could provide and, therefore, they could not readmit the client. Furthermore, the facility never issued a proper 30-day eviction notice nor advised Community Care Licensing via Special Incident Report (SIR) of this incident.
Based on the preponderance of evidence gathered through multiple interviews, record review, and collected documents, the allegation "Facility abandoned client at the hospital" is substantiated.
The facility is being cited for a violation of Title 22, Division 6 of the California Code of Regulations.
An exit interview was conducted with the house manager (HM), and a copy of this report, along with information regarding appeal rights, was provided at the conclusion of the visit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20250411093950
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: JIDDE RESIDENTIAL HOME III
FACILITY NUMBER: 306004689
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
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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: 04/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3