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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004761
Report Date: 03/09/2026
Date Signed: 03/09/2026 03:55:31 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
03/02/2026 and conducted by Evaluator Sean Haddad
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20260302125450
FACILITY NAME:CAMBRIDGE COURTFACILITY NUMBER:
306004761
ADMINISTRATOR:LAUREN CHONFACILITY TYPE:
740
ADDRESS:1621 COMMONWEALTH AVENUE, EASTTELEPHONE:
(714) 992-1750
CITY:FULLERTONSTATE: CAZIP CODE:
92831
CAPACITY:99CENSUS: 82DATE:
03/09/2026
UNANNOUNCEDTIME BEGAN:
07:36 AM
MET WITH:Hannah ChoeTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Facility has insufficient staff to provide care and supervision to residents
INVESTIGATION FINDINGS:
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of investigating the above-mentioned complaint allegation. LPA met with Staff #1 (S1) Hannah Choe, discussed the purpose of the inspection, and explained the allegation. Administrator (AD) Lauren Chon appeared via telephone.

The investigation into the allegation that the facility has insufficient staff to provide care and supervision to residents revealed the following: During the course of the investigation, LPA inspected the facility, interviewed AD, residents, and staff, and obtained and reviewed copies of the resident roster, staff roster, the facility’s staff schedule, and the facility’s payroll records.

CONTINUED
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2026
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 3
Control Number 22-AS-20260302125450
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: CAMBRIDGE COURT
FACILITY NUMBER: 306004761
VISIT DATE: 03/09/2026
NARRATIVE
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It was alleged that the facility does not have enough staff, when the elevator was temporarily down recently the facility did not have enough staff to help residents get up and down the stairs, and during a recent weekend there was only one medication technician and one caregiver on duty. LPA inspected the facility, conducted health and safety checks on residents, and observed no health and safety issues. Per the facility’s resident roster, the facility has 82 residents. LPA interviewed AD who stated the facility is always trying to improve staffing, and although there are callouts, the facility has always had enough staff to meet residents’ needs. LPA interviewed the facility’s wellness coordinator who stated that the staff schedule provides for one medication technician for each shift and three caregivers for the day shift, two or three caregivers for the afternoon shift, and two caregivers for the overnight shift. Per the facility’s wellness coordinator, two caregivers plus a medication technician is sufficient to meet the needs of the residents. LPA reviewed the facility’s staff schedule which generally shows there is one medication technician scheduled per shift, three caregivers scheduled for the day shifts, and two caregivers scheduled for the overnight shift. LPA reviewed the facility’s payroll records which shows that on Saturday, February 28, 2026, both caregivers that were scheduled for the afternoon shift of 2:30PM to 10:30PM called out, one of the three caregivers that were scheduled for the morning shift stayed late to cover until 6:30PM, and a backup staff was called to cover from 5:00PM until 10:30PM. Based on these payroll records, in addition to the medication technician, there was only one caregiver between 2:30PM and 5:00PM and again from 6:30PM to 10:30PM on Saturday, February 28, 2026, which is lower than the two care staff that would be sufficient to meet residents’ needs per the facility’s wellness coordinator and lower than the three care staff planned for by the staff schedule. LPA interviewed 10 residents and obtained corroborating information that staffing at the facility is sometimes short, particularly on weekend evenings, leading to staff being spread too thin and rushing care for residents and not providing enough individual attention. The resident interviews provided conflicting information regarding staff helping residents up and down the stairs during the period the elevator was down and did not provide information indicating that short staffing led to any injuries or incidents involving residents. The information obtained corroborated that the facility did not have sufficient staff to meet residents’ needs, but did not corroborate any immediate threat or harm to residents in this instance.

During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20260302125450
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: CAMBRIDGE COURT
FACILITY NUMBER: 306004761
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/09/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/23/2026
Section Cited
CCR
87411(a)
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87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.... This requirement was not met as evidenced by:
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Licensee stated they will create a plan to improve staffing, including a contingency plan for staff callouts, and submit proof to LPA by POC due date.
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Based on documents and interviews, the licensee did not ensure the facility had sufficient staff, including by having only one caregiver on February 28, 2026, resulting in rushed care for residents, which poses a potential safety 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: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3