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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005782
Report Date: 04/08/2026
Date Signed: 04/08/2026 11:19:24 AM

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
01/22/2026 and conducted by Evaluator Garlli Tat
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20260122083457
FACILITY NAME:RESPIT MANOR MISSION VIEJOFACILITY NUMBER:
306005782
ADMINISTRATOR:MENDEZ, MARKFACILITY TYPE:
740
ADDRESS:23412 VIA GUADIXTELEPHONE:
(949) 331-7578
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: DATE:
04/08/2026
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Michael AbadaTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Facility is not providing food of good quality.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Garlli Tat made an unannounced visit to the facility to deliver the findings on the above allegation. LPA met with facility representative and explained the purpose of the visit.
During the investigation, the following was completed: LPA inspected the facility, interviewed staff and residents, obtained and reviewed food receipts and staff schedules.
The investigation revealed the following:

It was alleged that facility is not providing food of good quality.
LPA toured the facility kitchen on January 29, 2026 and March 27, 2026. On March 27, LPA observed the fridge’s temperature was within range. During the food inspection visit, LPA verified the facility met the minimum two-day perishable supply and seven-day nonperishable supply. LPA observed that facility food supplies and groceries are purchased using facility credit/debit cards shared by the facility including food receipts. Continued on LIC9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Garlli Tat
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2026
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-20260122083457
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: RESPIT MANOR MISSION VIEJO
FACILITY NUMBER: 306005782
VISIT DATE: 04/08/2026
NARRATIVE
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Witness reported that some of the food is collected from a food bank. It was reported that food deliveries are on Thursdays or Fridays from Sam’s Club. During the food inspection LPA observed blueberry muffins in the fridge with an expiration date of March 22, 2026 is expired. One out of five witnesses interviewed confirmed that the fruits are overripe on occasions and not edible for consumption.

Based on evidence gathered through interviews and document review, the preponderance of evidence has been met, therefore, the above allegation are found to be Substantiated. Violations are being cited per Title 22 of California Code of Regulations. See LIC 9099-D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with authorized representative and a copy of this LIC9099 and LIC9099-D, along with a copy of the Appeal Rights were left at the facility.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Garlli Tat
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 22-AS-20260122083457
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: RESPIT MANOR MISSION VIEJO
FACILITY NUMBER: 306005782
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/15/2026
Section Cited
CCR
87555(b)(8)
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General Food Service Requirements
(b) The following food service requirements shall apply:
(8) All food shall be of good quality. [...].
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Staff disposed of food item immediately during the visit. Deficiency cleared during the visit. Licensee agrees to review all perishable and non-perishable food items on a weekly basis and dispose of any items that have exceeded the expiration dates.
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This requirement was not met as evidenced by: Based on observations and interviews, the licensee did not ensure that all expired foods stored at the facility were disposed of, which poses an immediate health and safety risk to persons in care.
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Licensee will provide training to all staff regarding the Title 22 regulation 87555 General Food Service Requirements and will provide proof of the training to LPA by POC due date.
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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: Sheila Santos
LICENSING EVALUATOR NAME: Garlli Tat
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
01/22/2026 and conducted by Evaluator Garlli Tat
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20260122083457

FACILITY NAME:RESPIT MANOR MISSION VIEJOFACILITY NUMBER:
306005782
ADMINISTRATOR:MENDEZ, MARKFACILITY TYPE:
740
ADDRESS:23412 VIA GUADIXTELEPHONE:
(949) 331-7578
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: DATE:
04/08/2026
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Michael AbadaTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Facility does not have sufficient staffing.
Resident's needs are not being met.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Garlli Tat made an unannounced visit to the facility to deliver the findings on the above allegations. LPA met with authorized representative and explained the purpose of the visit.
During the investigation, the following was completed: LPA inspected the facility, interviewed staff and residents, obtained and reviewed food receipts and staff schedules.
The investigation revealed the following:

It was alleged that facility does not have sufficient staffing. Based on observation, there were two staff present per LPA visits, on January 29, 2026, and March 27, 2026. LPA interviewed residents and staff. LPA obtained and reviewed facility work schedule and observed the facility has 24-hour staff coverage. Three out of five staff reported that there was an instance in which only one caregiver was on shift, who was able to provide supervision for the residents. Two out of two residents interviewed confirmed that there is usually at least one staff member on duty for resident supervision and was never left unsupervised. Continued on LIC9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Garlli Tat
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20260122083457
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: RESPIT MANOR MISSION VIEJO
FACILITY NUMBER: 306005782
VISIT DATE: 04/08/2026
NARRATIVE
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It was alleged that residents’ needs are not being met. Based on observation, all residents appeared clean and well-groomed during the visits on January 29, 2026, and March 27, 2026. Five out of five interviews conducted with staff confirmed that residents’ needs were being met. Staff reported that they assist residents as needed. Two out of two residents interviewed confirmed that their needs were being met. Interviews with witnesses and one resident explained that staff comes quickly when the call button is pressed. Witness confirmed that residents have met all their needs.

Based on evidence gathered during this investigation, although the allegations may have happened or are valid, there is not a preponderance of evidence to provide the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. An exit interview was conducted with Authorized representative, and a copy of the report was reviewed and provided during the visit.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Garlli Tat
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5