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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005835
Report Date: 06/16/2026
Date Signed: 06/16/2026 03:27:38 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
02/22/2026 and conducted by Evaluator Andrea Mendivil
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20260222214303
FACILITY NAME:KIRKWOOD ORANGEFACILITY NUMBER:
306005835
ADMINISTRATOR:ZEHRA SYEDFACILITY TYPE:
740
ADDRESS:1525 E TAFT AVENUETELEPHONE:
(714) 282-1409
CITY:ORANGESTATE: CAZIP CODE:
92865
CAPACITY:66CENSUS: 48DATE:
06/16/2026
UNANNOUNCEDTIME BEGAN:
12:16 PM
MET WITH:Erin Palposi - Executive Director TIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff did not properly inform resident's responsible party of the resident's change of condition.
Staff did not properly report incident to resident's responsible party.
Staff does not treat residents in care with respect.
INVESTIGATION FINDINGS:
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On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the facility and explained the reason for the visit.

The Department received a complaint on Feburary 22 2026 and the initial 10 day visit was conducted on Feburary 27,2026. LPA Mendivil obtained copies of records including assessments, physician's reports, admission agreements, emails regarding rate change and email correspondence. LPA Mendivil interviewed staff and residents. Regarding the allegations staff did not properly inform resident's responsible party of the resident's change of condition, staff did not properly report incident to resident's responsible party, and staff does not treat residents in care with respect the investigation revealed the following:

It was alleged that staff did not properly inform resident's responsible party of the resident's change of condition. Per interviews with former nurse Putri Tarigan staff will report changes of condition to her and she will inform families.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2026
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-20260222214303
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: KIRKWOOD ORANGE
FACILITY NUMBER: 306005835
VISIT DATE: 06/16/2026
NARRATIVE
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Interviews with 3 out of 5 residents stated that their responsible parties have been informed of change of condition when something happens to them. The remaining two residents did not have issues with change of condition.

It was alleged that Staff did not properly report incident to resident's responsible party. Interviews with 6 out of 6 staff stated all incidents are reported to responsible parties. Interviews with 3 out of 5 residents stated if there is an incident their responsible parties are informed either via calls or emails. The remaining 2 residents did not have incidents occur.

It was alleged Staff does not treat residents in care with respect. Interviews with 6 out of 6 staff stated they treat all residents with respect. Interviews with 5 out of 5 residents stated they are treated with respect by all staff.

Therefore based on the preponderance of evidence through interviews and observations the allegations Staff did not properly inform resident's responsible party of the resident's change of condition, Staff did not properly report incident to resident's responsible party, and Staff does not treat residents in care with respect are determined to be UNSUBSTANTIATED, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred.

No deficiencies cited. An exit interview was conducted and a copy of this report this report was left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2