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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006071
Report Date: 12/30/2025
Date Signed: 12/30/2025 11:58:58 AM

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
12/24/2025 and conducted by Evaluator Brandon Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20251224103733
FACILITY NAME:PALMS RETIREMENT CENTERFACILITY NUMBER:
306006071
ADMINISTRATOR:BAHADORY, KHATERAFACILITY TYPE:
740
ADDRESS:312 N ROOSEVELT AVETELEPHONE:
(626) 353-4710
CITY:FULLERTONSTATE: CAZIP CODE:
92832
CAPACITY:144CENSUS: 105DATE:
12/30/2025
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Assistant Administrator Kathleen TamondongTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff inappropriately communicate with resident
INVESTIGATION FINDINGS:
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On December 30, 2025, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to initiate the investigation into the allegation listed above and to deliver the complaint findings. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Assistant Administrator (AA) Kathleen Tamondong was notified via telephone and later arrived to assist with the inspection.

On today's visit, LPA, accompanied by the AA, conducted a tour of the physical plant of the facility. LPA observed the facility to be clear of any obstructions or hazards. LPA conducted six resident interviews and five staff interviews. LPA also collected pertinent documents to the complaint such as the current resident roster, the current staff roster, and resident records.

Regarding the allegation that, staff inappropriately communicate with resident, the following has been concluded: CONTINUED ON LIC9099-C
Substantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2025
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 5
Control Number 22-AS-20251224103733
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: PALMS RETIREMENT CENTER
FACILITY NUMBER: 306006071
VISIT DATE: 12/30/2025
NARRATIVE
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It was alleged that a facility staff spoke inappropriately to R1 after she sustained her unwitnessed fall. LPA conducted an interview with R1 who confirmed the allegation and stated that a facility staff insulted her after she sustained her unwitnessed fall. LPA conducted an additional five resident interviews regarding their experience with facility staff. Two out of the five residents interviewed stated that a facility staff has also spoken to them in an inappropriate manner such as with rude or mean comments. However, three of out of five residents interviewed denied staff ever speaking to them in an inappropriate manner and stated that they believe staff are friendly. LPA also conducted five staff interviews. Two out of the five staff interviewed denied the allegation and stated that they have never witnessed or heard of staff speaking to a resident in an inappropriate manner. However, three out of the five staff interviewed confirmed the allegation. The three staff stated that they are aware of previous incidents in which a staff has spoken to a resident in an inappropriate manner. Additionally, two of the staff interviewed stated that they have personally witnessed a staff speak inappropriately to a resident. LPA conducted a total of eleven interviews for this complaint, including interviews with residents and staff. Out of the eleven people interviewed, six people corroborated the complaint allegation.

Based on the evidence gathered during this investigation, the Department obtained sufficient evidence to substantiate the allegation that, staff inappropriately communicate with resident. The preponderance of evidence standards has been met; therefore, the above allegation is SUBSTANTIATED. A deficiency is being cited on the attached LIC9099-D. An exit interview was conducted with Assistant Administrator Kathleen Tamondong. A copy of the report and Appeal Rights were provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
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
12/24/2025 and conducted by Evaluator Brandon Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20251224103733

FACILITY NAME:PALMS RETIREMENT CENTERFACILITY NUMBER:
306006071
ADMINISTRATOR:BAHADORY, KHATERAFACILITY TYPE:
740
ADDRESS:312 N ROOSEVELT AVETELEPHONE:
(626) 353-4710
CITY:FULLERTONSTATE: CAZIP CODE:
92832
CAPACITY:144CENSUS: 105DATE:
12/30/2025
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Assistant Administrator Khatera BahadoryTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff did not tend to resident's fall in a timely manner
INVESTIGATION FINDINGS:
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On December 30, 2025, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to initiate the investigation into the allegation listed above and to deliver the complaint findings. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Assistant Administrator (AA) Kathleen Tamondong was notified via telephone and later arrived to assist with the inspection.

On today's visit, LPA, accompanied by the AA, conducted a tour of the physical plant of the facility. LPA observed the facility to be clear of any obstructions or hazards. LPA conducted six resident interviews and five staff interviews. LPA also collected pertinent documents to the complaint such as the current resident roster, the current staff roster, and resident records.

Regarding the allegation that, staff did not tend to resident's fall in a timely manner, the following has been concluded: CONTINUED ON LIC9099-C
Unsubstantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 22-AS-20251224103733
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: PALMS RETIREMENT CENTER
FACILITY NUMBER: 306006071
VISIT DATE: 12/30/2025
NARRATIVE
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It was alleged that facility staff did not attend to Resident #1 (R1) in a timely manner after she sustained an unwitnessed fall on an unknown date. LPA reviewed the facility's charting notes and observed that R1 had a documented fall at the facility on November 24, 2025, at approximately 3:50 AM. 9-1-1 was called and R1 was transported to the hospital. LPA conducted an interview with R1. R1 said that she had rolled out of her bed and that she was on the floor for approximately one hour before a facility staff found her. R1 said that because of her condition, she was unable to pull the call cord in her bedroom that would have alerted staff. LPA conducted an interview with R1's roommate, Resident #2 (R2). However, R2 was unable to provide any information on how long R1 might have been on the floor before she was assisted by a facility staff. LPA conducted five staff interviews. Two out of the five staff interviewed were unable to provide any useful information for the complaint allegation. Three out of the five staff interviewed denied the allegation and stated that R1 was assisted in a timely manner after she sustained her unwitnessed fall. LPA conducted an additional three resident interviews. Three out of the three resident interviewed stated that staff have always helped them in a timely manner.

Due to conflicting information gathered during this investigation, 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 Assistant Administrator Kathleen Tamondong and a copy of the report was provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 22-AS-20251224103733
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: PALMS RETIREMENT CENTER
FACILITY NUMBER: 306006071
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/30/2026
Section Cited
CCR
87468.1(a)(1)
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87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not evidenced by:
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The Assistant Administrator stated that they will conduct an in-service training with all facility staff regarding the personal rights of residents. The Assistant Administrator agreed to provide LPA proof of training via email or fax by POC date.
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Based on a total of eleven interviews conducted with both residents and staff, the Licensee did not ensure that resident's are spoken appropriately to by staff. This poses a potential health, safety, and personal rights 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: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5