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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004761
Report Date: 07/15/2026
Date Signed: 07/15/2026 03:53:52 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
06/22/2026 and conducted by Evaluator Brandon Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20260622113246
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: 83DATE:
07/15/2026
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Executive Director Lauren ChonTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Facility did not report power outage to the Department
Facility did not have emergency lighting available during power outage
Facility is not conducting quarterly emergency drills
Facility is not following their emergency disaster plan
INVESTIGATION FINDINGS:
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On July 15, 2026, Licensing Program Analysts (LPAs) Brandon Lopez and Tran Nguyen made an unannounced visit to the facility to deliver the complaint findings. LPAs were greeted and granted entry into the facility by staff after explaining the purpose for the visit. Executive Director Lauren Chon was present and assisted on today's visit.

During the course of the investigation, the Department interviewed eight residents and five staff. The Department also reviewed and obtained pertinent documents to the complaint such as the facility's emergency disaster drill training's and the facility's emergency disaster plan. Regarding the allegation, facility did not report power outage to the Department, the following has been concluded: During the investigation, the Department conducted eight resident interviews. Eight out of the eight residents interviewed confirmed the facility experienced a power outage on June 19, 2026. The Department conducted five staff interviews, including with the facility's Executive Director. Five out of the five staff interviewed also confirmed that the facility experienced a power outage on June 19, 2026. CONTINUED ON LIC9099-C
Substantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2026
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-20260622113246
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: CAMBRIDGE COURT
FACILITY NUMBER: 306004761
VISIT DATE: 07/15/2026
NARRATIVE
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LPAs observed that the facility conducted an emergency disaster drill in the second quarter of 2026, however, the facility only conducted the training with the overnight staff. The facility did not conduct the training with the morning or afternoon shift staff as required per regulations. The Department conducted five staff interviews. Three staff interviewed confirmed that they did not participate in an emergency disaster drill in the second quarter of 2026.

Regarding the allegation, facility is not following their emergency disaster plan, the following has been concluded: During the investigation, the Department reviewed the facility's emergency disaster plan. Per the facility's emergency disaster plan on page six, it states" If there is a need for more power the facility is prepared to rent an additional generator from Home Depot. It states that if the emergency call system becomes inoperable, staff will implement a manual check-in and visual monitoring. It further states that caregivers will perform request safety rounds 15-30 minutes or as needed. Lastly, it states that during power outages or emergencies, battery operated and back-up oxygen tanks will be made available for residents using concentrators." The Department conducted five staff interviews. Five out of the five staff interviewed confirmed that the facility did not rent a generator from Home Depot as stated in their emergency disaster plan. Three staff interviewed confirmed that facility was also unable to complete safety rounds every 15-30 minutes as stated in their emergency disaster plan due to lack of staffing. Staff interviewed also confirmed that the facility did not have back-up oxygen tanks available for the four residents of the facility that require oxygen. The staff interviewed reported that the four residents went without oxygen and were just monitored during the approximate nine hour power outage. The Department conducted eight resident interviews. Eight out of the eight resident interviewed also corroborated the allegation. The eight resident confirmed that the facility did not have a generator present during the power outage. The eight residents confirmed that staff did not complete safety rounds every 15-30 minutes. The residents interviewed reported that staff only checked on them one or twice during the entire power outage which lasted approximately nine hours.

Based on the evidence gathered during this investigation, the Department obtained sufficient evidence to substantiate the four allegations listed above. The preponderance of evidence standards has been met; therefore, the above allegations are SUBSTANTIATED. Deficiencies are being cited on the attached LIC9099-D pages. An exit interview was conducted with Executive Director Lauren Chon. A copy of the report and appeal rights were provided at time of visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 22-AS-20260622113246
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: CAMBRIDGE COURT
FACILITY NUMBER: 306004761
VISIT DATE: 07/15/2026
NARRATIVE
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California Code of Regulations, Title 22 Section 87211(a)(1)(d) states the following: "(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident." LPAs observed that the facility submitted an Unusual Incident/Injury Report to the Orange County Regional Office regarding the facility's power outage on July 2, 2026, which is thirteen days after the incident occurred, and therefore six days past the required time frame.

Regarding the allegation, facility did not have emergency lighting available during power outage, the following has been concluded: During the investigation, the Department confirmed that the facility experienced a power outage on June 19, 2026. The Department conducted eight resident interviews. Eight out of the eight resident interviews corroborated the allegation. The eight residents interviewed reported that the facility did not have sufficient flashlights available during the power outage. Resident interviewed reported that staff present during the outage had to rely on their personal cell phones for lighting. Resident interviewed reported that residents also allowed staff to borrow their own personal flashlights so that the staff could perform their job duties. The Department conducted five staff interviews. Three out of the five staff also corroborated the allegation and reported that the facility did not have sufficient flashlights available for the power outage. The staff interviewed confirmed that they had to rely on their personal cell phones, and they had to borrow flashlights from residents, in order to complete their job duties.

Regarding the allegation, facility is not conducting quarterly emergency drills, the following has been concluded: Per Health & Safety Code Section 1569.695(c), it states: "(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill." During the course of the investigation, LPAs reviewed the facility's quarterly emergency drill training's. CONTINUED ON LIC9099-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 22-AS-20260622113246
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: CAMBRIDGE COURT
FACILITY NUMBER: 306004761
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/27/2026
Section Cited
HSC
1569.695(c)
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ยง1569.695 Emergency Plans: (c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios.
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The Executive Director stated that she will have the two remaining shifts complete an emergency disaster drill. The Executive Director agreed to provide LPA proof of the emergency disaster drill via email or fax by POC due date.
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Based on records reviewed, the Licensee did not ensure that the morning or afternoon shifts conducted an emergency disaster drill in the second quarter of 2026. This poses a potential health and safety risk to persons in care.
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Type B
07/27/2026
Section Cited
CCR
87212(a)
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87212 Emergency Disaster Plan: (a) Each facility shall have a disaster and mass casualty plan of action. The plan shall be in writing and shall be readily available.
This requirement is not evidenced by:
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The Executive Director stated that she will complete a written statement that the facility will follow the emergency disaster plan. The Executive Director stated that she will also conduct a training with all staff regarding the facility's emergency disaster plan procedures. The Executive Director stated that she will
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Based on records reviewed and interviews conducted, the Licensee did not ensure that the facility followed the emergency disaster plan during the power outage that occurred on June 19, 2026. This poses a potential health and safety risk to persons in care.
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provide LPA the written statement and the training via email or fax by POC due date.
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: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 22-AS-20260622113246
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: CAMBRIDGE COURT
FACILITY NUMBER: 306004761
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/27/2026
Section Cited
CCR
87211(a)(1)(d)
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87211 Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports.. (1) A written report shall be submitted to the licensing agency .. within seven days..(D) Any incident which threatens the welfare, safety or health of any resident..
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The Executive Director stated that she will complete a written statement that the facility will abide by the regulation cited. The Executive Director agreed to provide LPA the written statement via email or fax by POC due date.
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This requirement is not evidenced by: Based on records reviewed, the Licensee did not ensure that the facility submitted a written report for the power outage that occurred on June 19, 2026, within seven days. This poses a potential health and safety risk to persons in care.
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Type B
07/27/2026
Section Cited
CCR
87303(h)
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87303 Maintenance and Operation: (h) Emergency lighting shall be maintained. At a minimum this shall include flashlights, or other battery powered lighting, readily available in appropriate areas accessible to residents and staff...
This requirement is not evidenced by:
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The Executive Director stated that she has already purchased additional emergency lightings for the facility after the power outage. The Executive Director stated that she will conduct a training with the staff regarding the locations of emergency lighting. The Executive Director agreed to provide
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Based on interviews conducted, the Licensee did not ensure that the facility had sufficient emergency lighting available during the power outage that occurred on June 19, 2026. This poses a potential health and safety risk to persons in care.
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LPA proof of the training via email or fax by POC due date.
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: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5