306005730-5-13-2026-22-AS-KSGH-DVMPV2-20260703113822

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005730
Report Date: 05/13/2026
Date Signed: 05/13/2026 11:47:57 AM

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
07/28/2025 and conducted by Evaluator Jerome Haley

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20250728155238

FACILITY NAME:	MERIDIAN AT ANAHEIM HILLS, THE		FACILITY NUMBER:	306005730
ADMINISTRATOR:	PELLICER, RAY		FACILITY TYPE:	740
ADDRESS:	525 S ANAHEIM HILLS ROAD		TELEPHONE:	(714) 974-2226
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92807
CAPACITY:	120	CENSUS: 75	DATE:	05/13/2026
		UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Ray Pellicer		TIME COMPLETED:	11:55 AM

ALLEGATION(S):

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Resident developed unstageable pressure injury due to staff neglect
Facility staff did not notify resident's family about pressure injuries
Facility staff locked residents in their bedrooms
Facility staff did not adequately supervise residents during showers

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit to the facility to deliver findings on the allegations listed above. LPA was greeted and granted entry by staff after introducing himself and stating the purpose of the visit.

The complaint investigation was initiated by LPA Sean Haddad on July 29, 2025, regarding a complaint filed on July 28, 2025. The complaint was investigated by the Department and consisted of a tour of the physical plant, a review of medical records obtained from hospice providers, interviews with facility staff, and interviews with witnesses like medical professionals, resident family members, and a local ombudsman.

Regarding the allegation: Resident developed unstageable pressure injury due to staff neglect
During the investigation, 0 of 17 individuals provided any information or evidence that supports the complaint allegations and a majority of the information that was gathered during the investigation through interviews and document review contradicted the complaint allegation.
Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2026

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 5

Control Number 22-AS-20250728155238

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: MERIDIAN AT ANAHEIM HILLS, THE	FACILITY NUMBER: 306005730
	VISIT DATE: 05/13/2026

NARRATIVE

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During an interview with Executive Director Ray Pellicer, caregivers are instructed to notify med tech if they observe any skin concerns. Med techs report to the Memory Care Director Ira Lustina, and Ira will contact the doctor and family.

When Memory Care Director Lustina was asked about facilities protocol when it comes to pressure injuries, she said, Med techs will report to me… if it’s a stage one hospice will provide a skin barrier cream or ointment. If it’s stage two, hospice will come and treat the wound. If the residents on Home Health, they will come treat it as well. If it’s unstageable, we send them out. We report it to the doctor first then they will order for us to send them to the hospital or skilled nursing. We’re not allowed to treat or stage a pressure wound so we report it to the doctor first.

Document review was consistent with the information gathered during interviews. The care team would reposition residents who had pressure wounds, document the time the resident was repositioned and make additional notes regarding status or condition of the resident (what side they are laying on). The documentation was consistent and it was documented the same over an extended period of time. The documentation style was consistent and followed a pattern that was used by all different staff, and used on all different residents, Residents 1 (R1), Resident 2 (R2), and Resident 3 (R3). All three residents were on hospice and were receiving wound care.

Regarding the allegation: Facility staff did not notify residents family about pressure injuries

During the investigation 0 of 17 individuals provided any information or evidence that supports the complaint allegation. Based on interviews, record review, and due to the lack of information provided when the complaint was filed, much of the information gather contradicts the complaint allegation.

During the investigation all five staff members who were asked about the allegation provided a consistent response and it was clear the staff understood their responsibility and know how to respond to pressure injuries appropriately. When the executive director was asked how staff are trained to respond to pressure wounds, executive director stated, the med tecs will report to Memory Care Director, and [The Memory Care Director] will call the doctor, family, and get a treatment order.

Continued on LIC9099C pg 2 of 5

SUPERVISORS NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 22-AS-20250728155238

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: MERIDIAN AT ANAHEIM HILLS, THE	FACILITY NUMBER: 306005730
	VISIT DATE: 05/13/2026

NARRATIVE

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The Memory Care Director Lustina was asked the same question about how staff respond when they see a pressure injury and she said, Med techs will report to me… if it’s a stage 1 Hospice will a skin barrier or ointment if it’s stage 2 Hospice will come and treat the wound if they’re on HH they will come treat it as well. If it’s unstageable, we send them out... we report to the doctor first then they will order for us to send the resident to the hospital or skilled nursing. We are not allowed to treat or stage a pressure wound so we report it to the doctor first.

According to Staff 3 (S3), if it’s more than stage one, we usually do home health or if they’re on hospice they do the care. We turn the residents every two hours… If the pad comes off, we call hospice to change it because we can’t. If it’s stage one and they prescribe cream, we can apply the cream, but when the wounds opens, we contact the doctor.

Document review revealed, facility staff documented consistently and took good notes on each resident. Facility staff would document when residents were repositioned, information about the pressure wounds when necessary, document the time the resident was repositioned, and make additional notes regarding status or condition of the resident during the required check. It was clear the facility uses an effective documenting process and the documentation style was consistent that remains consistent with the different staff, as well as with different residents. A review of resident records for R1, R2, and R3 who were all receiving wound care was all documented the same way over an extended period of time.

Facility staff also ensured outside providers like Home Health and Hospice providers were required to fill out outside agency forms with contact information and notes about the residents’ condition and care. Providers fill out forms and document the status of residents’ condition after each visit, consistently.

Regarding the allegation: Staff locked residents in their bedroom

0 of 17 individuals provided any information or evidence that supports the complaint allegation. All staff who were asked about residents being locked in their room denied the allegation. According to Executive Director the opposite is happening and Executive Director states, if anything the residents are out of their room too much. Memory Care Director Lustina strongly denied the allegation and said, we don’t lock residents in their room… How can we lock them in if the lock is on the inside.

Continued on LIC9099C pg 3 of 4

SUPERVISORS NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 22-AS-20250728155238

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: MERIDIAN AT ANAHEIM HILLS, THE	FACILITY NUMBER: 306005730
	VISIT DATE: 05/13/2026

NARRATIVE

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Staff 3 (S3) said, “No.” when asked the question. S3 was then asked about whether there have been complaints or concerns from family members and S3 denied there had been any complaints or concerns from family members. Staff 5 (S5) said, “No.” We never lock doors. They’re (residents) the ones who lock their door. Like this morning the door was locked for one of the residents.

During the investigation, interviews were conducted with six different family members of residents in the memory care unit. All of the family members denied residents are locked in rooms. However, a couple family members did acknowledge they were informed the room doors are locked for a couple days if one of the residents display wandering behaviors and begin to enter rooms that don't belong to them. Another family member stated they were informed they doors are locked if another resident is entering resident rooms. All other family members denied the allegation and said no when asked if residents are locked in their rooms.
One family member said their loved one's door is always open.

Regarding the allegation: Facility staff did not adequately supervise residents during showers

0 of 17 individual were able to provide any supporting details or information that supports the complaint allegation.

All the staff who were interviewed denied the allegation and provided information the opposes the allegation.
According to the Memory Care Director, each care staff has their list of residents on who to shower. Residents in memory care always say no. If they refuse, we come back in an hour, if they refuse we try again later. Memory Care Director also confirmed that a staff member is present at all times when residents are being showered.

Staff 3 (S3) was asked about the showering process and said, “I don’t do it much because I’m the med tech.” S3 explained, each shower schedule is twice a week. If the resident is on hospice, the hospice provider administers the shower. S3 explained, if they don’t want to shower, we fill out a paper they refused, and we let the boss know they don’t want to shower. Staff 5 did not provide any information that supports the allegation and said, “We usually give them a sponge bath and get them up if they are not on the schedule for showers.

Continued on LIC9099C pg 4 of 5

SUPERVISORS NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2026

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 22-AS-20250728155238

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: MERIDIAN AT ANAHEIM HILLS, THE	FACILITY NUMBER: 306005730
	VISIT DATE: 05/13/2026

NARRATIVE

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According to staff 4 (S4), residents have showers at least twice a week. S4 explained, ideally, we try to shower them in the morning… if they have a preference, we try to honor that… If they refuse a shower, we attempt to shower them later. If they refuse again, we endorse the PM shift, and they take over and try and get the shower done then.

A family member of a memory care resident, was asked if there were any concerns with the supervision at the facility and the family member, strongly denied, and said, No… No.

Based on the information gathered through interviews, document review, and observation, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, the allegations are deemed unsubstantiated.

SUPERVISORS NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2026

LIC9099 (FAS) - (06/04)

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