306005322-6-17-2026-22-AS-LMOA-DWDAHD-20260727001411

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005322
Report Date: 06/17/2026
Date Signed: 06/17/2026 04:40:06 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
08/20/2025 and conducted by Evaluator Edward Kim

COMPLAINT CONTROL NUMBER: 22-AS-20250820085829

FACILITY NAME:	ACTIVCARE AT YORBA LINDA		FACILITY NUMBER:	306005322
ADMINISTRATOR:	ENRIQUE LEDESMA		FACILITY TYPE:	740
ADDRESS:	4725 VALLEY VIEW AVE		TELEPHONE:	(714) 577-8005
CITY:	YORBA LINDA	STATE: CA	ZIP CODE:	92886
CAPACITY:	80	CENSUS: 53	DATE:	06/17/2026
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Marketing Director- Shannen Buckholz		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Resident sustained injury due to lack of care from staff

INVESTIGATION FINDINGS:

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On June 17, 2026, 1:00 PM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced subsequent complaint visit to deliver findings at the above facility for the above allegation. LPA Kim met with Marketing Director Shannon Buckholz and explained the purpose of the visit. Administrator Enrique Ledesma was out of the office for the week, and the Facility Designee of Responsibility is Marketing Director Buckholz.

The investigation consisted of the following: LPA Kim conducted a physical tour of the facility. LPA Kim reviewed and obtained copies of staff roster, resident roster, staff schedule, and one resident’s record, which include: Admission Agreement, Identification and Emergency Information, Physician's Report, Needs and Services Plans/Appraisal, Progress notes, Incident reports, and other pertinent records.

The investigation revealed the following:
Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2026

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-20250820085829

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: ACTIVCARE AT YORBA LINDA	FACILITY NUMBER: 306005322
	VISIT DATE: 06/17/2026

NARRATIVE

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Allegation: Resident sustained injury due to lack of care from staff
It is alleged that the resident had noticeable multiple bruises on their face, purple and green color, bilateral cheeks, right jaw, and noticeable swelling on right forehead from a lack of care from staff.

Based on record review, Resident #1's (R1) Physician Report dated January 24, 2025, diagnoses R1 with major depressive disorder and dementia. It is noted on Facility charting notes, many incidents with R1 having behavioral issues such as impulse behavioral issues and not following staff direction, which led to the incident where R1 had multiple bruises due to an unwitnessed fall.

Facility Incident Report dated on July 30, 2025, R1 was sent to the hospital due to an unwitnessed fall, falling face first to the ground. R1 was found to have full range of motion and hematoma to the right side of their face and a scratch on the bridge of their nose. Facility charting notes dated July 30, 2025, also confirmed the Incident Report, which stated R1 was sent to the hospital due to an unwitnessed fall where R1 fell to the ground face first with injury to their face. Hospital record dated on July 30, 2025, confirmed the fall and hematoma right forehead.

Facility Charting Notes dated on August 3, 2025, due to the fall from July 30, 2025, R1 was noted with skin discoloration to right eye, left eye, and cheek. It was noted R1 did not complain of pain or discomfort. Facility Charting Notes dated August 5, 2025, due to the fall from July 30, 2025, it is noted there is a continuation of facial discoloration and swelling from R1’s forehead. It is also noted a yellowish and greenish discoloration to the right side of face/cheek. Purplish and greenish discoloration to bilateral eye area. After Visit Summary hospital record dated on August 17, 2025, stated R1 was sent to the hospital on August 17, 2025 due to agitation, and was discharged from the facility on August 22, 2025. Facility Charting notes dated August 22, 2025, at 6:00PM, that R1 returned to the facility from the hospital. Prior to the hospitalization on August 17, 2025, Resident still had some bruises remaining prior to being admitted to the hospital.

Based on interviews, five staff denied the allegation. One resident could not confirm or deny the allegation. Five staff stated the resident did not sustain an injury due to lack of care from staff. Five staff stated the resident had behavioral issues due to impulse and agitation. Staff #1 (S1) stated that the R1 had a fall on July 30, 2025, and staff responded in a timely manner. R1 was sent to the hospital for the unwitnessed fall
Continued on LIC9099-C

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2026

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20250820085829

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: ACTIVCARE AT YORBA LINDA	FACILITY NUMBER: 306005322
	VISIT DATE: 06/17/2026

NARRATIVE

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due to hematoma on their right forehead and scratch on the bridge of their nose. S2 stated the resident returned to the facility on the same day based on reviewing the charting notes. S2 recalls the bruising getting worse on the right side of their eye and also bruising to the left side. S2 stated it is common for a fall of that nature where discoloration and bruising to show up progressively after the initial fall. S2 stated the bruising would take some time before it healed and was very likely it didn’t heal completely prior to R1’s hospitalization on August 17, 2025.

Based on information gathered, there is not sufficient evidence to corroborate the above allegation.

Based on records review, interviews, and observations, LPA did not find sufficient evidence to support the above allegation Resident sustained injury due to lack of care from staff. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview was conducted a copy of the report was provided to Marketing Director Shannen Buckholz.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2026

LIC9099 (FAS) - (06/04)

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