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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005527
Report Date: 09/03/2025
Date Signed: 09/03/2025 10:23:28 AM

Unfounded


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
02/14/2024 and conducted by Evaluator Jerome Haley
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240214081820
FACILITY NAME:AGAPE SENIOR HOMES LLCFACILITY NUMBER:
306005527
ADMINISTRATOR:FISCHER, LONNIEFACILITY TYPE:
740
ADDRESS:11442 NEWPORT AVETELEPHONE:
(714) 393-2308
CITY:SANTA ANASTATE: CAZIP CODE:
92705
CAPACITY:6CENSUS: 4DATE:
09/03/2025
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Conrado Sta CruzTIME COMPLETED:
10:35 AM
ALLEGATION(S):
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Questionable death
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jerome Haley made an unannounced follow up visit regarding the complaint allegation above. LPA explained the purpose for the visit upon entry.

Regarding the allegation above, document review reveal, R1 was admitted to hospice on December 2, 2023, with a diagnosis of ASCVD, Co-Morbidities include Lymphoma, Prostate Cancer, CVA with right sided weakness (hemiplegia), TIAs, Atrial fib, depression, falls with hip, rib, and elbow fractures; failure to thrive, HTN, migraines, UTI, anxiety disorder, and dysphagia.

Regarding the care R1 received at the facility, hospice document review stated the following: the two male care staff members are very kind, compassionate, and helpful to R1. It is evident that R1 is well nourished, well hydrated, well groomed, well taken care of, and manage to promote his physical, nutritional, and emotional well being.

Continued on LIC9099C
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
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 2
Control Number 22-AS-20240214081820
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: AGAPE SENIOR HOMES LLC
FACILITY NUMBER: 306005527
VISIT DATE: 09/03/2025
NARRATIVE
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During the investigation it was discovered R1 communicated to staff that the resident did not feel well. Staff contacted R1’s daughter and hospice provider. R1’s hospice provider arrived and placed R1 on a comfort kit. R1 passed away at the facility at 2:08pm surrounded by several family members including R1’s daughter, sister, dad, brother and others.

Upon review of the certificate of death, the cause of death was A) Cardiopulmonary Failure B) Arteriosclerotic Cardiovascular Disease which is consistent with R1’s diagnosis upon admission to hospice December 2, 2023.

Based on the information gathered through document review, and observations the allegation is deemed unfounded, meaning the allegation is false, could not have happened and/or is without a reasonable basis.

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

DATE: 09/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2