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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006031
Report Date: 03/19/2026
Date Signed: 03/19/2026 03:21:14 PM

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
12/03/2025 and conducted by Evaluator Garlli Tat
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20251203153959
FACILITY NAME:PORT MINOAFACILITY NUMBER:
306006031
ADMINISTRATOR:ROCHE, RYANFACILITY TYPE:
740
ADDRESS:25601 MINOA DRIVETELEPHONE:
(949) 859-8391
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 6DATE:
03/19/2026
UNANNOUNCEDTIME BEGAN:
01:32 PM
MET WITH:Scott Messick, Ryan RocheTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Resident fell multiple times due to staff neglect.
Resident sustained injuries due to staff neglect.
Staff are not awake for the night shift.
Staff did not call emergency services for resident.
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 administrators, Scott Messick and Ryan Roche 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 resident records including Admission Agreement, Medical Assessment dated September 4, 2025, Appraisal, Needs and Services plan, emergency contact information.

The investigation revealed the following:

It was alleged that Resident 1 (R1) fell multiple times due to staff neglect.
R1 moved to the facility on September 4, 2025, and moved out of the facility on October 10, 2025. Based on interviews conducted, R1 had three unwitnessed incidents of falls, on September 7, 2025, September 11, 2025, and September 23, 2025. On September 11, 2025, this fall incident resulted in a hospital visit. None of the falls were reported to the Department. Continued LIC9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Garlli Tat
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2026
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 9
Control Number 22-AS-20251203153959
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: PORT MINOA
FACILITY NUMBER: 306006031
VISIT DATE: 03/19/2026
NARRATIVE
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LPA attempted to interview R1 and no response was received. Five out of five residents interviewed did not witness R1’s fall incidents. R1’s medical assessment dated September 4, 2025, shows R1 is diagnosed with Alzheimer’s Disease and engages in unsafe wandering, exhibits lack of hazard awareness, and requires monitoring for safety. R1 was under hospice care at the time of move-in. LPA attempted to contact the hospice nurse to request R1’s hospice records, however the hospice company is no longer in business.

LPA obtained hospital records dated September 11, 2025, that show R1 was treated for the fall incident. Per R1’s physicians report dated September 4, 2025, R1 had a wandering and lack of hazard awareness behavior that was not in the facility plan of care. Per hospital record dated September 11, 2025 the CT-scan on R1, show no acute lumbar abnormality of spine, no evidence of traumatic intrathoracic injury of chest, no evidence of traumatic intra-abdominal/pelvic injury, no evidence of acute cervical abnormality of cervical spine, no acute intracranial abnormality of the head, and no acute fracture or dislocation along the right elbow. There is soft tissue swelling posterior to the elbow.

Four out of four staff interviewed reported that R1 had a fall mat next to R1’s bed to help reduce the risk of injury. LPA observed during the review of facility records that the fall mat is not documented in the facility fall prevention plan. Four out of four staff interviewed had stated that R1 was a fall risk and R1 does not ask for help when ambulating or transferring. R1 had a one-on-one caregiver hired by R1 family and a bed alarm was implemented. The facility did not implement any other procedures to mitigate R1’s fall risk.

It was alleged that resident (R1) sustained multiple injuries due to staff neglect.

Based on interviews conducted, R1 had three unwitnessed incidents of falls, on September 7, 2025, September 11, 2025, and September 23, 2025. LPA attempted to interview R1 and was unsuccessful. Four out of four staff interviewed reported that R1 had a fall mat next to R1’s bed to help reduce the risk of injury. Record review revealed that R1’s medical assessment dated September 4, 2025, shows R1 is diagnosed with Alzheimer’s Disease and engages in unsafe wandering, exhibits lack of hazard awareness, and requires monitoring for safety. R1 requires assistance with bathing, grooming, and toileting needs. On September 11, 2025, R1 had a fall, resulting in a swollen elbow. On September 17, 2025, a large bruise was noticed on R1’s back. Four out of four staff interviewed were unable to pinpoint the cause. On October 1, 2025, R1’s left leg became stuck between the bed rails. Based on photo evidence, R1 sustained a bruise on her left knee as a result. Staff 1 (S1) admitted that staff do not go to check on residents every few hours. Continued on LIC9099-C.

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

DATE: 03/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2026
LIC9099 (FAS) - (06/04)
Page: 8 of 9
Control Number 22-AS-20251203153959
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: PORT MINOA
FACILITY NUMBER: 306006031
VISIT DATE: 03/19/2026
NARRATIVE
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It was alleged that Staff are not awake for night shift.

Records review revealed that R1’s physician’s report dated September 4, 2025, R1 is diagnosed with Alzheimer’s Disease and engages in unsafe wandering, lacks hazard awareness, and is at risk for elopement. These issues are not addressed in R1’s care plan. Per plan of operation, the facility maintains “trained staff 7 days a week and 24 hours a day.” Due to R1’s inability to alert staff at night, and staff not being awake to monitor R1, staff are unable to care for R1 during the night shift. Interview with four out of four staff confirmed caregivers are asleep during the nighttime. Two out of four staff reported R1 is unable to use the call button.

It is alleged that Staff did not call emergency services for resident.

On October 1, 2025, resident's leg got stuck between the bed rails. Responsible Party instructed staff to call 911. Responsible Party’s brother arrived at the facility and was able to dislodge R1’s leg. Hospice nurse arrived later to assess the resident and provided an assessment of R1’s leg and body. R1 sustained a bruise and wound care was provided by hospice nurse. Three out of four staff admitted that 911 was not called because Responsible Party was able to dislodge R1’s leg safely. There was no documentation of emergency services being called.

Based on evidence gathered through interviews and documentation review, the preponderance of evidence has been met, therefore, the above allegations 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 Administrator, Scott Messick and a copy of this LIC9099, 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: 03/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2026
LIC9099 (FAS) - (06/04)
Page: 9 of 9
Control Number 22-AS-20251203153959
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: PORT MINOA
FACILITY NUMBER: 306006031
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/19/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/20/2026
Section Cited
CCR
87464(f)
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(f) Basic services shall at a minimum include:
(1) Care and supervision as defined in Section 87101(c)(3) and [...] 1569.2(c).
This requirement was not met as evidenced by:
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Licensee agrees to train all staff on CCR 87464 and will submit a written plan within 24hrs to schedule staff training and will follow up to provide the proof of training to LPA by March 31, 2026.
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Based on documents and interviews, the licensee did not ensure R1 received care and supervision, as a result R1 suffered multiple injuries because of falls, which poses an immediate health and safety risk to persons in care.
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Type A
03/20/2026
Section Cited
CCR
87465(g)
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(g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified [...].
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Licensee agrees to submit a written plan within 24hrs to schedule all staff training and will follow up to provide the proof of training to LPA by March 31, 2026.
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This requirement was not met as evidenced by: Based on record review and interviews, the licensee did not call 911 when R1’s leg was lodged between the bedrails on October 1, 2025, resulting in bruising, which poses an immediate health and safety risk to persons in care.
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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: 03/19/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 9
Control Number 22-AS-20251203153959
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: PORT MINOA
FACILITY NUMBER: 306006031
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/19/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/20/2026
Section Cited
CCR
87705(2)
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For facilities with fewer than 16 residents, ensuring there is at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal, or observation, to require awake night supervision.
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Licensee agrees to adhere to CCR 87705 and to sign a statement of understanding and submit proof to LPA within 24hrs by March 20, 2026. Licensee will submit a written plan to LPA regarding awake staff supervision for residents who are
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This requirement was not met as evidenced by: Based on record review and interviews, the licensee did not have an awake night staff person on duty even though R1 was observed to engage in wandering and lacks hazard awareness.
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wanderers or in need of supervision at night. This is due by March 31, 2026.
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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: 03/19/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 9
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
12/03/2025 and conducted by Evaluator Garlli Tat
COMPLAINT CONTROL NUMBER: 22-AS-20251203153959

FACILITY NAME:PORT MINOAFACILITY NUMBER:
306006031
ADMINISTRATOR:ROCHE, RYANFACILITY TYPE:
740
ADDRESS:25601 MINOA DRIVETELEPHONE:
(949) 859-8391
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 6DATE:
03/19/2026
UNANNOUNCEDTIME BEGAN:
01:32 PM
MET WITH:Scott Messick, Ryan RocheTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff did not allow resident to place a camera in resident’s room.
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 administrators Scott Messick and Ryan Roche 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 resident records including Admission Agreement, Medical Assessment dated September 4, 2025, Appraisal, Needs and Services plan, and emergency contact information.

The investigation revealed the following:
It was alleged that staff did not allow resident to place a camera in resident’s room. On January 12, 2026, LPA conducted a tour of the resident bedroom and did not observe a camera in R1’s shared bedroom. Two out of four staff interviewed reported that they are not aware of any cameras placed in resident’s bedroom. Continued LIC9099-C.



Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Garlli Tat
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2026
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 9
Control Number 22-AS-20251203153959
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: PORT MINOA
FACILITY NUMBER: 306006031
VISIT DATE: 03/19/2026
NARRATIVE
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Two out of four staff interviewed reported that they are aware that an exception must be made if a camera were to be placed in R1’s bedroom. Four out of four staff stated a camera was never implemented in R1’s shared bedroom. Resident interviews confirmed that no one has a camera in their rooms.

Based on the evidence gathered, the allegation is deemed Unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. The Department has therefore dismissed the complaint.

An exit interview was conducted with the Administrators and a copy of this LIC9099 report was left at the facility.

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

DATE: 03/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 9
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
12/03/2025 and conducted by Evaluator Garlli Tat
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20251203153959

FACILITY NAME:PORT MINOAFACILITY NUMBER:
306006031
ADMINISTRATOR:ROCHE, RYANFACILITY TYPE:
740
ADDRESS:25601 MINOA DRIVETELEPHONE:
(949) 859-8391
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 6DATE:
03/19/2026
UNANNOUNCEDTIME BEGAN:
01:32 PM
MET WITH:Scott Messick, Ryan RocheTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff are not meeting resident's needs.
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 administrators, Scott Messick and Ryan Roche 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 resident records including Admission Agreement, Medical Assessment dated September 4, 2025, Appraisal, Needs and Services plan, and emergency contact information.
The investigation revealed the following:

It is alleged that staff are not meeting residents’ needs. Record review revealed that R1’s medical assessment dated September 4, 2025, shows R1 is diagnosed with Alzheimer’s Disease and engages in unsafe wandering, exhibits lack of hazard awareness, and requires monitoring for safety. Continued on LIC9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Garlli Tat
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 9
Control Number 22-AS-20251203153959
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: PORT MINOA
FACILITY NUMBER: 306006031
VISIT DATE: 03/19/2026
NARRATIVE
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R1 requires assistance with bathing, grooming, and toileting needs. Interviews with two out of four staff reported they assist residents when they hear the call alarm. R1’s family retained a private caregiver between the dates of 9/11/25-9/16/25, 9/17/25-9/20/25, 9/23/25-9/27/25, 10/1/25-10/10/25. R1 only had 1 fall on September 23, 2025, during that time. Interviews with two out of four staff stated they made it clear to family that the facility has live-in caregivers who sleep at night. LPA attempted to interview R1 but was unsuccessful. Interviews with five out of five residents stated they’ve never needed assistance at night and are unable to confirm whether staff come to assist when they need help.

Based on the evidence gathered during this investigation, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

An exit interview conducted with Administrators, and a copy of the report was reviewed and provided. Appeal rights provided.

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

DATE: 03/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2026
LIC9099 (FAS) - (06/04)
Page: 7 of 9