306005911-10-9-2025-22-AS-SSAS-DMWVT2-20251029164226

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005911
Report Date: 10/09/2025
Date Signed: 10/09/2025 12:04:22 PM

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
12/23/2024 and conducted by Evaluator Joseph Alejandre

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20241223121400

FACILITY NAME:	CREMONA VILLA		FACILITY NUMBER:	306005911
ADMINISTRATOR:	GOLDSTEIN, ERIC S.		FACILITY TYPE:	740
ADDRESS:	23661 CREMONA		TELEPHONE:	(949) 436-3331
CITY:	LAGUNA HILLS	STATE: CA	ZIP CODE:	92653
CAPACITY:	6	CENSUS: 4	DATE:	10/09/2025
		UNANNOUNCED	TIME BEGAN:	11:01 AM
MET WITH:	Sheey Dizon		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Lack of care and supervision resulting in resident sustaining serious injuries
Lack of care and supervision resulting in resident sustaining multiple falls

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the complaint investigation into the allegations listed above. LPA met with Administrator (AD) Sherry Dizon and explained the reason for the visit. During the course of the investigation, Department staff inspected the facility, interviewed AD, witnesses, and staff, and obtained and reviewed records, including resident roster, staff roster, staff schedule, Resident 1’s (R1) physician’s reports dated March 6, 2024 and January 7, 2025, R1’s appraisal/needs and services plan dated April 3, 2024, R1’s preplacement appraisal dated 1/9/24, Incident report for R1 dated December 21, 2024 and Hoag Hospital records dated December 21, 2024 to December 23, 2024.

The investigation into the allegation, lack of care and supervision resulting in resident sustaining serious injuries, revealed the following. Resident 1 (R1) moved into the facility on March 3, 2024. R1 has been diagnosed with Mild Cognitive Impairment, hypertension and hyperlipemia. R1’s physician reported dated March 6, 2024, lists R1 as non-ambulatory.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025

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 3

Control Number 22-AS-20241223121400

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: CREMONA VILLA	FACILITY NUMBER: 306005911
	VISIT DATE: 10/09/2025

NARRATIVE

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At 1:30 am on December 21, 2024, R1 was found by Staff 1 (S1) kneeling next to their bed. S1 asked R1 what happened and R1 could not recall how they got on the floor. R1 requested assistance to use the bathroom. S1 reported they assessed R1, and no injuries were noted and R1 denied any pain or discomfort. S1 reported they escorted R1 to use the bathroom and then escorted R1 back to bed. S1 reported that R1 stated they were fine. S1 reported that they did not report the fall to the morning caregivers. R1 could not recall the incident. R1 went back to bed and later that day in the morning Staff 2 (S2) assisted R1 in getting dressed and served R1 breakfast. At 13:30 hours on December 21, 2024, a barber came to the facility and gave R1 a haircut. After the haircut was completed, R1 complained of immense pain on their right side as S2 transferred R1 from the chair to their wheelchair. S2 called 911 and paramedics transferred R1 to Hoag Hospital. S2 reported that R1 did not report any pain or discomfort until after his haircut. S1 did not report the fall until after R1 was taken to the hospital. R1 was admitted to Hoag Hospital on December 21, 2024, with the diagnosis of acute, minimally displaced or non-displaced fractures of the right 8 – 11 ribs. R1 was discharged back to the facility on December 23, 2024, with orders for a low hospital bed and a Hoyer lift to assist with transfers. R1 has only suffered one fall while residing at the facility and staff assisted R1 right after the fall. S1 assessed R1, and no injuries were noted. R1 did not report any injuries or pain.
Based on the interviews conducted and documents reviewed, the Department is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the allegation is deemed UNSUBSTANTIATED.

The investigation into the allegation, lack of care and supervision resulting in resident sustaining multiple falls, revealed the following. Resident 1 (R1) moved into the facility on March 3, 2024. R1 has been diagnosed with Mild Cognitive Impairment, hypertension and hyperlipemia. R1’s physician reported dated March 6, 2024, lists R1 as non-ambulatory. R1’s Responsible Party reported that R1 had numerous falls at home prior to moving to the facility. The Responsible Party stated that R1 falling was the primary reason for moving R1 into a facility. The Responsible Party reported that they are unaware of R1 falling at the facility except for the fall on December 21, 2024. 4 out of 4 staff interviewed reported that R1 has only had one fall on December 21, 2024. R1 did not recall the fall incident on December 21, 2024. R1 denied having falls at the facility. A review of incident reports for the facility from March 1, 2024, to December 31, 2024, shows the only fall reported for R1 took place on December 21, 2024. R1 was hospitalized for the fall on December 21, 2024, due to fracturing their ribs.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 22-AS-20241223121400

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: CREMONA VILLA	FACILITY NUMBER: 306005911
	VISIT DATE: 10/09/2025

NARRATIVE

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R1 was discharged back to the facility on December 23, 2024, with an order for a low hospital bed and a Hoyer lift to assist with transfers. There has not been any reported falls or hospitalizations since R1 has returned to the facility.

Based on the interviews conducted and documents reviewed, the Department is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the allegation is deemed UNSUBSTANTIATED.

An exit interview was conducted with the Administrator and a copy of the report was provided.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025

LIC9099 (FAS) - (06/04)

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