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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005554
Report Date: 03/24/2026
Date Signed: 03/24/2026 02:18:05 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
12/04/2025 and conducted by Evaluator Jessica Cho
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20251204124305
FACILITY NAME:DEVOTED HEART CARE HOMES LLCFACILITY NUMBER:
306005554
ADMINISTRATOR:KEVIN CLARKFACILITY TYPE:
735
ADDRESS:26665 AVENIDA SHONTOTELEPHONE:
(818) 384-9331
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:4CENSUS: 4DATE:
03/24/2026
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Laura Palomino- AdministratorTIME COMPLETED:
02:40 PM
ALLEGATION(S):
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Facility mismanaged client's medication.
INVESTIGATION FINDINGS:
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On March 24, 2026, Licensing Program Analyst (LPA) Jessica Cho made an unannounced visit for the purpose of continuing the complaint investigation into the above allegation. LPA met with Administrator Laura Palomino and stated the reason for the visit. During the course of the investigation, LPA attempted interviews with one client/three witnesses, a fourth witness, one staff and obtained the following documentation for review: Client Rosters, Personnel Report Summary, Face Sheet, Admission Agreement, Preplacement Appraisal, Individual Program Plan, Daily Progress Notes, Social/Leisure/Recreation Log, Incident Reports, and Medication Administration Records (MAR) for August 2025 concerning Client #1 (C1).

Regarding the allegation, Facility mismanaged client's medication, it is alleged that C1's supply of Depakote was missing for the month of August 2025. Based on an interview, one of one staff indicated that C1's representative informed staff that they had miscounted the medication and mistakenly counted the medication in error.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2026
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-20251204124305
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: DEVOTED HEART CARE HOMES LLC
FACILITY NUMBER: 306005554
VISIT DATE: 03/24/2026
NARRATIVE
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One interviewed witness confirmed that the text message sent to facility staff on August 15, 2025 at 7:16pm indicated that medication count was accurate. Based on the review of C1's MAR for the month of August 2025, C1 was prescribed two medications, Depakote and Risperidone. There were a total of 8 days in August 2025 C1 did not receive their medication(s) evidenced by some days were either left blank or marked with a (-) which signifies "not given" per the administrator. LPA verified via the back of the MAR, progress notes, and/or the Social/Leisure/Recreation Log that C1 had home visits on seven out of the eight days and the medications were not administered at the facility but administered at home. C1 received both medications in the morning and afternoon as prescribed on August 8th. However, there were no documentation as to why medications were not given at bedtime on August 8th. One staff interviewed indicated that C1 went to program on Friday, August 8th and would get picked up by their family for a home visit over the weekend. Document shows that C1 had a home visit continuing on Sat, August 9th and Sunday, August 10th. Documents also prove that there were another week, C1 would have a home visit starting Friday and throughout the weekend.

Therefore, based on interviews which were conducted and the records that were reviewed, 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 following allegation: Facility mismanaged client's medication is deemed UNSUBSTANTIATED.

An exit interview was conducted with Administrator Laura Palomino, and a copy of this report including the LIC811 were provided at the end of the visit.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 4