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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004795
Report Date: 05/15/2026
Date Signed: 05/15/2026 03:40:35 PM

Unsubstantiated


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
02/04/2026 and conducted by Evaluator Alvaro Ramirez Jr.
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20260204150603
FACILITY NAME:WESTMINSTER VILLAFACILITY NUMBER:
306004795
ADMINISTRATOR:PATTY OSUNAFACILITY TYPE:
740
ADDRESS:13881 DAWSON STREETTELEPHONE:
(714) 534-7880
CITY:GARDEN GROVESTATE: CAZIP CODE:
92843
CAPACITY:200CENSUS: 105DATE:
05/15/2026
UNANNOUNCEDTIME BEGAN:
01:46 PM
MET WITH:Maria P Osuna-AdministratorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Resident sustained a fracture due to lack of care or neglect from staff
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on an investigation completed by the Department. LPA was greeted and granted entry into the facility by Administrator (AD) Maria P. Osuna.

During the course of the investigation, the Department interviewed staff and witnesses as well as reviewed and obtained documentation such as Physician Reports (LIC602), Identification and Emergency Information, Resident Appraisal, Unusual Incident/Injury Report (UIIR), Roster of Facility Residents, and Staff schedule. The Department has investigated the complaint alleging that Resident sustained a fracture due to lack of care or neglect from staff. Resident 1 (R1) was admitted to the facility on December 14, 2021. R1’s Physician Report dated May 23, 2024, lists R1 as having a diagnosis of Hypertension. During the interviews with individuals five of eight interviewed denied the allegation. During the investigation LPA reviewed documents including the Physician report for R1. Per Physician report, R1 is ambulatory.
CONTINUED ON LIC9099-C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2026
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-20260204150603
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: WESTMINSTER VILLA
FACILITY NUMBER: 306004795
VISIT DATE: 05/15/2026
NARRATIVE
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LPA reviewed the UIIR dated January 18, 2026, for R1. Per UIIR, on January 18, 2026, R1 was taken to the hospital due to having a fall while jumping up and down the stairs. The Department also reviewed the UCI Health Fountain Valley Medical Records dated January 18, 2026, for R1. Per Medical Records, R1 reported that he missed the last step while walking downstairs and sustained a femoral neck fracture. During the interviews with R1’s Physician’s Assistant (PA) it was reported that R1’s care plan had been established in 2021 and remains in place. Per PA, R1 was nonambulatory in 2021 but became ambulatory and independent after regaining mobility following a successful knee surgery in 2022. Per PA, R1 is not a fall risk. The PA reported that an assisted device was recommended; but not required. During the interviews with residents R1 stated that the fall was an accident and reported that he chose to use the stairs based on personal preference. R3 and R4 stated that the residents have not sustained a fracture due to lack of care and/or supervision from staff. During the interviews with staff, S1-S2 reported that R1 did not sustain a fracture due to lack of care and supervision.

Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegation occurred as reported due to insufficient evidence. Therefore, the allegation has been deemed to be UNSUBSTANTIATED.

LPA Ramirez conducted an exit interview with AD Osuna, and a copy of this report was provided to the facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
02/04/2026 and conducted by Evaluator Alvaro Ramirez Jr.
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20260204150603

FACILITY NAME:WESTMINSTER VILLAFACILITY NUMBER:
306004795
ADMINISTRATOR:PATTY OSUNAFACILITY TYPE:
740
ADDRESS:13881 DAWSON STREETTELEPHONE:
(714) 534-7880
CITY:GARDEN GROVESTATE: CAZIP CODE:
92843
CAPACITY:200CENSUS: 105DATE:
05/15/2026
UNANNOUNCEDTIME BEGAN:
01:46 PM
MET WITH:Maria P Osuna-AdministratorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Facility is in disrepair
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on the above allegation received on February 04, 2026. LPA was greeted and granted entry into the facility and met with Administrator (AD) Maria P. Osuna. LPA explained the reason for the visit.

This Department has investigated the complaint alleging that facility is in disrepair. Regarding the allegation, the following was revealed: During the initial visit on February 5, 2026, and subsequent visit on May 8, 2026, LPA tour the facility and observed that the main elevator next to the front desk is broken. LPA observed that the second elevator by the activities room is working properly. During the interviews with individuals six of eight interviewed confirmed the allegation. During the interviews with residents, R1, R2, R4, and R5 stated that one elevator is not working and/or reported that the elevator has not been working for months. During the interviews with staff, Staff 1 (S1) and S2 reported that the elevator by the front is in disrepair.

CONTINUED ON LIC9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 22-AS-20260204150603
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: WESTMINSTER VILLA
FACILITY NUMBER: 306004795
VISIT DATE: 05/15/2026
NARRATIVE
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Based on the evidence gathered, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. The facility is cited per Title 22, Division 6 of the California Code of Regulations.

An exit interview was conducted and a copy of this report, LIC9099-D, and Appeal Rights were provided.
An exit interview was conducted with AD Osuna, and a copy of this report was left at the facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20260204150603
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: WESTMINSTER VILLA
FACILITY NUMBER: 306004795
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/15/2026
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation (a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidence by:
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Per AD, the elevator will be replace in Mid June. Licensee to email LPA documentation confirming the elevator repair has been completed.
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During the visit on 2/5/26, 5/8/26 and 5/15/26 LPA tour the facility and observed that the main elevator next to the front desk is broken. This poses a potential health, safety, and personal rights risk to people 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: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5