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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005330
Report Date: 05/21/2025
Date Signed: 05/21/2025 03:28:41 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
05/21/2025 and conducted by Evaluator Jerome Haley
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250521091117
FACILITY NAME:DE'ROUX FAMILY HOMEFACILITY NUMBER:
306005330
ADMINISTRATOR:EXILDA COOPERFACILITY TYPE:
735
ADDRESS:1559 MUSTANG AVETELEPHONE:
(714) 744-4495
CITY:ORANGESTATE: CAZIP CODE:
92869
CAPACITY:4CENSUS: 0DATE:
05/21/2025
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Exilda CooperTIME COMPLETED:
02:29 PM
ALLEGATION(S):
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Medication is not being administered as prescribed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jerome Haley made unannounced visit to begin the investigation into the complaint received May 13, 2025. LPA Haley was greeted by staff and explained the reason for the visit upon entry. During the visit, LPA Haley conducted an interview with the licensee, toured the facility, and took photos of key observations. Relevant documents were requested and will be provided via email by the close of business.

Regarding the allegation: Medication is not being administered as prescribed.

During the interview with staff 1 (S1) it was discovered that Client 1 (C1) is not currently taking any medications since C1 does not have medical coverage and does not receive any SSI benefits. S1 explained that C1 doesn’t have a birth certificate or social security card. According to S1, C1 was previously prescribed Seroquel and Depakote. The last time C1 received the medication is unclear, as there is no medication administration record (MAR) or medication list available for C1 at this time.
Continued on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025
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-20250521091117
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: DE'ROUX FAMILY HOME
FACILITY NUMBER: 306005330
VISIT DATE: 05/21/2025
NARRATIVE
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According to S1 request were made to address the lack of benefits for C1. S1 confirmed there was no order to stop either of the medications. C1 just ran out and did not receive a refill because his medical coverage expired.

Based on the evidence gathered through interviews the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. Violations are being cited per California Code of Regulations Title 22.

An exit interview was conducted and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20250521091117
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: DE'ROUX FAMILY HOME
FACILITY NUMBER: 306005330
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/22/2025
Section Cited
CCR
80075(a)
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(a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services.
This requirement was not being met as evidenced by:
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The licensee has requested a planning team meeting with the Regional Center staff to address C1's missing documentation needed to get C1’s medial and SSI benefits back in good standing. The licensee agrees to inform LPA Haley the date of the schedule meeting. POC is due by the close of business Thursday May 22, 2025.
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C1 has no medical coverage and does not have any medications available. It is unclear how long the client has not had medications; however, staff did confirm C1 has been without medical coverage for at least two months.
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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: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3