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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005827
Report Date: 04/23/2026
Date Signed: 05/08/2026 09:59:53 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
08/31/2023 and conducted by Evaluator Samer Haddadin
COMPLAINT CONTROL NUMBER: 22-AS-20230831105029
FACILITY NAME:COZY HOME SENIOR CAREFACILITY NUMBER:
306005827
ADMINISTRATOR:DUMALIANG, CZARINA SFACILITY TYPE:
740
ADDRESS:22272 TERNITELEPHONE:
(949) 583-9365
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY:6CENSUS: 4DATE:
04/23/2026
UNANNOUNCEDTIME BEGAN:
08:05 AM
MET WITH:Paris DumaliangTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Facility is a hostile environment for residents.
Facility has no proper ventialtion resulting in residents rooms being hot.
Resident was able to leave facility unassisted.
Resident are left unasssited.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced visit to deliver findings regarding the above-mentioned allegations. LPA was granted entry by Administrator (AD) Paris Dumaliang and explained the purpose of the visit. At the time of the visit, there were three staff members working and four residents in care.
During the course of the investigation, LPA interviewed staff, reviewed facility records, conducted a health and safety walk-through of the facility, and attempted to interview current residents. LPA also attempted to contact the reporting party by telephone on three separate dates; however, LPA was unable to obtain additional information from the reporting party.
It was alleged that “Facility is a hostile environment for residents,” “Residents are left unassisted,” “Resident was able to leave facility unassisted,” and “Facility has no proper ventilation resulting in residents’ rooms being hot.”
{***CONTINUE9099C***} {***THIS IS AN AMENDED REPORT***}
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2026
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 2
Control Number 22-AS-20230831105029
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: COZY HOME SENIOR CARE
FACILITY NUMBER: 306005827
VISIT DATE: 04/23/2026
NARRATIVE
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LPA conducted interviews with three staff members. All three staff members denied the allegations. Staff denied that the facility is a hostile environment and stated that residents are treated respectfully. Staff also denied that residents are left unassisted and stated that staff are available to assist residents as needed. Staff further denied that any resident, including Resident 1 (R1), left or attempted to leave the facility unassisted. LPA attempted to interview residents; however, due to residents’ cognitive limitations, LPA was unable to obtain reliable statements from residents to support or refute the allegations. During staff interviews, staff stated that R1 could not have left the facility unassisted because R1 required assistance with ambulation and used a walker. LPA reviewed R1’s admission agreement and physician’s report. The records reviewed indicated that R1 was not receiving hospice services, had mild cognitive dementia, was non-ambulatory, and used a walker. Staff also denied any known elopement incidents involving R1 or any other resident. LPA observed exit alarms and door chimes in the facility. LPA also reviewed the Department’s system and facility records and did not observe any incident reports or records showing a known elopement incident. LPA conducted a health and safety walk-through of the interior and exterior areas of the facility. During the walk-through, LPA did not observe the facility to be a hostile environment for residents. Residents observed during the visit appeared calm and were not observed to be in distress. LPA observed staff present and available to assist residents as needed. LPA did not observe residents being left unassisted, and LPA did not observe any resident exiting or attempting to leave the facility unassisted. Regarding the allegation that the facility had no proper ventilation, LPA observed the facility to have adequate ventilation during the visit. Resident rooms inspected by LPA did not appear excessively hot or uncomfortable. LPA observed that windows were operable, the HVAC/air conditioning system was functioning, fans were present, and the thermostat was working properly. Based on the information gathered during the investigation, including staff interviews, records reviewed, and LPA’s observations, the Department is unable to determine that the allegations occurred as reported. Although the allegations may have happened or may be valid, there is not a preponderance of evidence to prove or disprove that the alleged violations occurred. Therefore, the allegations are deemed Unsubstantiated. An exit interview was conducted, and a copy of this report was provided to AD Paris Dumaliang. {***THIS IS AN AMENDED REPORT***}
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2