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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006071
Report Date: 12/24/2025
Date Signed: 12/24/2025 02:18:23 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
07/01/2025 and conducted by Evaluator Samer Haddadin
COMPLAINT CONTROL NUMBER: 22-AS-20250701132137
FACILITY NAME:PALMS RETIREMENT CENTERFACILITY NUMBER:
306006071
ADMINISTRATOR:BARRIENTOS, ELEANORFACILITY TYPE:
740
ADDRESS:312 N ROOSEVELT AVETELEPHONE:
(626) 353-4710
CITY:FULLERTONSTATE: CAZIP CODE:
92832
CAPACITY:144CENSUS: DATE:
12/24/2025
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:TIME COMPLETED:
02:18 PM
ALLEGATION(S):
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Facility failed to issue proper notification for rate increase
INVESTIGATION FINDINGS:
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{***This is an Amended***}
On July 15, 2025, Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced complaint investigation at the facility. Upon arrival, LPA Haddadin was greeted by Khatera Bahadory AD, who granted entry and was advised of the purpose of the visit.
During the investigation, the analyst toured the premises, residents and staff and reviewed all facility records concerning the allegation. The allegation under review stated that the facility failed to issue proper notification for a rate increase. The investigation revealed that on March 31, 2025, the facility provided R1 with a 60-day written notice of a rate increase, scheduled to take effect on May 31, 2025. During an interview with the LPA, Resident 1 (R1) confirmed receipt of the notice. Effective January 1, 2025, Residential Care Facility’s for the Elderly are required to provide residents a 90 days written notice of increasing rates of fees, or increasing any of its rate structures for services, to residents or their representatives. The written notice must include the amount of the increase, the reason or reasons for the increase, and a description of the additional costs, except for an increase in the rate due to a change in the level of care of the residents. Per 60 day written notice of rate increase provided to R1, rate increase was based off the facility raising their rate for basic services, no description of the additional costs was provided. Per R1’s Admission Agreement, R1 did not stipulate their source of income, meaning if their source of income was based on private pay and/or Social Security Income SSI). Therefore, the facility could not be expected to adhere to SSI payment standards for R1. Although the facility had the right to increase R1’s rate, the notice provided to R1 failed to meet 90 days written notice requirement. Therefore, based on observations, interviews, and the information gathered during the investigation, the preponderance of the evidence standard has been met. Therefore, the allegation that the Facility failed to issue proper notification for rate increase is deemed Substantiated. The following is being cited per California Code of Regulations Title 22 1569.655(a). An exit interview was conducted, and a copy of this report, Appeal Rights and Confidential Names List was provided to the Administrator.
*****AMENDED*****
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE:

DATE: 12/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/24/2025
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 2
Control Number 22-AS-20250701132137
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: 12/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
01/14/2026
Section Cited
CCR
1569.655(a)
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1569.655(a)If a licensee of a residential care facility for the elderly increases the rates of fees for residents or makes increases in any of its rate structures for services, the licensee shall provide no less than 90 days’ prior written notice to the residents
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Licensee will refund any money owed to R! and send proof of such to LPA by POC due date
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Based on record review, licensee failed to ensure R1 was given a 90 day notice This poses a potential health and safety risk to residents 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: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE:

DATE: 12/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/24/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2