306005334-8-28-2026-22-AS-AORZ-DXGTCV-20260831143723

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005334
Report Date: 08/28/2026
Date Signed: 08/28/2026 10:28:59 AM

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
03/17/2026 and conducted by Evaluator Andrea Mendivil

COMPLAINT CONTROL NUMBER: 22-AS-20260317142945

FACILITY NAME:	WONDER'S YEARS		FACILITY NUMBER:	306005334
ADMINISTRATOR:	JUAN M. GARCIA TRUJILLO		FACILITY TYPE:	740
ADDRESS:	24301 BARK STREET		TELEPHONE:	(949) 215-4087
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY:	6	CENSUS: 6	DATE:	08/28/2026
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Juan Garcia Trujillo - Licensee/Administrator		TIME COMPLETED:	10:45 AM

ALLEGATION(S):

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Resident sustained a severe pressure injury due to staff neglect

INVESTIGATION FINDINGS:

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On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry by staff and explained the reason for the visit.

The Department received a complaint on March 17, 2026, and the initial visit was conducted on March 18, 2026. The Department obtained copies of the following documents: Resident 1(R1) emergency contact information, R1’s medical assessment, and R1’s admission agreement. Regarding the allegation resident sustained a severe pressure injury due to staff neglect the investigation revealed the following:

R1 was admitted to the facility on January 17, 2026. Based on medical assessment dated January 14, 2026, R1 had a diagnosis of spinal stenosis and did not have a history of skin breakdown.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2026

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 4

Control Number 22-AS-20260317142945

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: WONDER'S YEARS	FACILITY NUMBER: 306005334
	VISIT DATE: 08/28/2026

NARRATIVE

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Per interview with Licensee/Administrator Juan Garcia Trujillo when R1 was admitted to the facility there was no pressure injuries noted. R1 experienced heart failure and was admitted to hospice on February 11, 2026. When R1 was admitted to hospice there was a stage 1 pressure injury on their back.
Per page four of Hospice IDG Comprehensive Assessment and Plan of Care Update Report it is stated “Skilled nursing to educate on skin breakdown prevention measures including: changing position at least every 2-3hrs..” It was noted on a hospice physician order dated February 26, 2026, R1 had both left buttock stage 2 pressure ulcer and left upper back stage 2 pressure injury as well as directions for cleaning and dressing both wounds. Subsequent visits on March 3, 2026, and March 6, 2026, note the pressure ulcers to be a stage 2 wound and hospice noted to increase their visits to three times per week due to coccyx wound infection. On March 10th 2026, it was noted that an unstageable pressure ulcer was on the coccyx. On March 13, 2026, hospice noted they need to evaluate and treat stage IV pressure injury to coccyx and mid back. On March 16, 2026, hospice notes indicated that R1 was found lying on dirty and soiled linens and appeared unclean as well as disheveled. Per interviews with hospice it was reported that R1’s hospice care plan was discussed with both the Licensee and caregiving staff and staff told the hospice nurse they were able to provide the care for R1.
Per interviews with staff and residents there was one caregiver in addition to the Licensee/Administrator, around February 23,2026 the only other available staff was unable to perform their duties. Per interviews with Licensee, Licensee stated that R1 would complain of pain during repositioning and incontinence checks. Licensee stated that they would change R1’s patches that covered the wounds but due to urine output the patches and wounds were wet. R1 had a foley catheter placed while on hospice. Licensee stated when he would try to reposition R1, R1 would cry and refuse to be repositioned. Licensee stated that he did not want to violate R1’s personal rights of refusal of medication treatment. Per hospice notes and review of hospice medication orders, R1 was prescribed the following for pain: tramadol to be given three times per day and morphine for the breakthrough pain.
Per review of hospice Client Coordination Note Report dated March 17, 2026, R1’s wound has progressed rapidly. It was also noted on Client Coordination Note Report that Licensee Juan Trullijo was consulted on multiple occasions to reposition R1 to prevent further issues with pressure ulcers. R1 passed away at the facility while on hospice on March 20, 2026.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 22-AS-20260317142945

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: WONDER'S YEARS	FACILITY NUMBER: 306005334
	VISIT DATE: 08/28/2026

NARRATIVE

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Therefore, based on the preponderance of evidence through records reviewed and interviews the allegation that resident sustained a severe pressure injury due to staff neglect determined to be Substantiated, meaning the complaint allegation is valid and that a violation has occurred.

A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49 (f)
See LIC9099-D for cited deficiencies and immediate civil penalty as per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with. A copy of this report, along with LIC9099-D, Appeal Rights, Civil Penalty Assessment-LIC 421 IM and the LIC 811, identifying confidential names were provided and explained

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2026

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20260317142945

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: WONDER'S YEARS	FACILITY NUMBER: 306005334
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/28/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/29/2026 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	Basic Services. Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).	1 2 3 4 5 6 7	Licensee stated will review all hospice care plans and adhere. Licensee stated will create care note document to document change of conditions/exceptions to baseline of residents. Licensee to provide LPA with proof by POC due date.
	8 9 10 11 12 13 14	This requirement was not met as evident by licensee did not follow hospice care plan of repositioning R1 resulting in unstageable wounds. This poses an immediate health and safety risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2026

LIC9099 (FAS) - (06/04)

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