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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005865
Report Date: 08/12/2026
Date Signed: 08/12/2026 09:57:41 AM

Unfounded


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
08/04/2026 and conducted by Evaluator Edward Kim
COMPLAINT CONTROL NUMBER: 22-AS-20260804095800
FACILITY NAME:RESPIT MANORFACILITY NUMBER:
306005865
ADMINISTRATOR:MENDEZ, MARKFACILITY TYPE:
740
ADDRESS:23255 RESPIT AVETELEPHONE:
(949) 460-0317
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY:6CENSUS: 4DATE:
08/12/2026
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Administrator- Mark MendezTIME COMPLETED:
10:15 AM
ALLEGATION(S):
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Staff did not issue responsible party a refund.
INVESTIGATION FINDINGS:
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On August 12, 2026, at 8:00 AM Licensing Program Analyst (LPA) Edward Kim conducted an unannounced initial complaint visit and delivered findings at the facility. LPA Kim met with Administrator (ADMIN) Mark Mendez and explained the purpose of the visit.

During today's visit, LPA Kim conducted a physical tour of the facility. LPA Kim reviewed and obtained copies of resident roster and staff roster. LPA conducted interviews with three staff and one witness.

The investigation revealed the following:

Continued on LIC9099C

Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2026
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-20260804095800
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
FACILITY NUMBER: 306005865
VISIT DATE: 08/12/2026
NARRATIVE
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Allegation: Staff did not issue responsible party a refund.
It is alleged the facility did not reimburse resident #1’s (R1) responsible person a refund after R1 passed away.

Based on interviews conducted, three staff and one witness denied the allegation. All three staff stated that R1 has never resided at the facility. S1 stated R1 has never lived at this facility location. Witness #1 (W1) confirmed this stating that R1 has never lived at this facility location. Based on record review, resident roster has never had R1 residing at this facility.

Based on observations made and records reviewed, LPA has determined that the investigation, through record review and interviews, the preponderance of evidence standard has not been met. Therefore, the allegation Staff did not issue responsible party a refund is deemed UNFOUNDED. We have found that the above allegation is unfounded, meaning that the allegation is false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted and a copy of this report was provided to Administrator Mark Mendez.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2