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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006071
Report Date: 07/15/2026
Date Signed: 07/15/2026 10:16:20 AM

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
09/23/2025 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250923153556
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: 110DATE:
07/15/2026
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Eric Vaca, Maria DimacaliTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Staff neglected resident resulting in severe dehydration and hospitalization
Staff did not address resident's change in condition
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 Maria Dimacali and the Director of Operations Eric Vaca and explained the reason for the visit.

During the course of the investigation, Department staff inspected the facility, interviewed the staff, witnesses and reviewed records, and reviewed voicemails messages, and reviewed documents including, resident roster, staff roster, staff schedule, Resident 1’s (R1) physician’s report dated June 2, 2022, R1’s preplacement appraisal dated May 31, 2022, elopement risk assessment dated May 15, 2022, R1’s functional capabilities assessment, R1’s Appraisal/Needs and Services Plan dated May 16, 2025, R1’s Admission Agreement dated May 13, 2025, R1’s consent for emergency medical treatment dated May 13, 2025, R1’s care notes for May and June 2025, R1’s physician’s report dated May 7, 2025, R1’s resident appraisal dated May 12, 2025, and St. Jude Medical Records for R1 dated July 7, 2025 to July 21, 2025.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2026
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 5
Control Number 22-AS-20250923153556
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: 07/15/2026
NARRATIVE
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The investigation into the allegation, staff neglected resident resulting in severe dehydration and hospitalization, revealed the following. It was reported that R1 was hospitalized on August 27, 2025, due to dehydration and a urinary tract infection (UTI) and subsequently sent to a Skilled Nursing Facility (SNF) because the facility failed to ensure R1 was properly fed and hydrated. A review of records shows that R1 moved to the facility on July 9, 2015. R1’s physician report dated September 12, 2024, shows R1 has been diagnosed with Parkinson’s Disease, Epilepsy, Hypothyroidism and Hypertension. R1 is able to leave the facility unassisted and handle their own cash resources. R1 is not conserved, has no power of attorney and makes all their own decisions. On August 27, 2025, staff noted R1 to be lethargic. Staff assessed R1 and decided to call 911. R1 was transported to the hospital and admitted for Acute cystitis without hematuria (UTI). R1 was at the hospital from August 27, 2025, to September 5, 2025. Hospital records dated August 27, 2025, to September 5, 2025, show R1 could be argumentative to staff and refused medication on August 28, 2025. Hospital notes for September 2, 2025, state patient (R1) has not been eating well, refusing most meals, does take medication. Hospital discharge paperwork for R1 shows R1 did not have adequate intake of food and water but does not meet the criteria for moderate or severe malnutrition. The recommendation is for R1 to drink Ensure Plus High Protein daily with meals and the goal is to eat 70% of all of their meals and snacks. R1 was discharged to a Skilled Nursing Facility (SNF) on September 5, 2025. R1 was at the SNF until October 1, 2025, when they returned to the facility. A review of records shows that R1 has refused food and water, and the facility documented those incidents. R1 did not eat or ate very little on August 5, 7, 10, 13 and 14, 2025. A review of records shows R1 was on home health visits from July 5, 2025, to October 24, 2025. The Home Health notes for August 27, 2025, state R1 has a poor appetite. The Administrator reported that after each incident R1’s primary care physician (PCP) and emergency contact were notified. R1’s emergency contact verified this report. R1 reported that they eat and drink when they feel like it and do not always eat three meals a day. R1 reported that they know how to get up and serve themselves water if need be. Staff reported that R1 was always encouraged to eat and drink and to let staff know if they needed anything. R1 verified this report. Based on the evidence gathered from interviews and a review of records, there is not enough evidence to prove that the staff failed to provide care or neglected R1, causing dehydration which resulted in hospitalization. Therefore, the allegation is deemed Unsubstantiated, meaning that, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 22-AS-20250923153556
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: 07/15/2026
NARRATIVE
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The investigation into the allegation, staff did not address resident's change in condition, revealed the following. It was reported that prior to their hospitalization on August 27, 2025, R1 was not getting out of bed and lost 20 pounds from June 2025 to September 15, 2025. A review of records shows that according to R1’s physician report dated September 12, 2024, R1 weighed 195 pounds. R1 was weighed at the hospital when they were admitted on August 27, 2025, and at the time of their discharge to the Skilled Nursing Facility (SNF) on September 5, 2025. R1 weighed 149 pounds on both dates. No other documents gathered during the investigation listed R1’s weight. R1 lost 46 pounds from September 12, 2024, to September 5, 2025. That is an average of just under 4 pounds a month. It is unknown how much weight R1 lost from June 2025 to September 2025. A review of records shows that R1 has refused food and water, and the facility documented those incidents. R1 did not eat or ate very little on August 5, 7, 10, 13 and 14, 2025. A review of records shows R1 was on home health visits from July 5, 2025, to October 24, 2025. The Home Health notes for August 27, 2025, state R1 has a poor appetite. The Administrator reported that after each incident R1’s primary care physician (PCP) and emergency contact were notified. R1’s emergency contact verified this report. R1 reported that they eat and drink when they feel like it and do not always eat three meals a day. R1 reported that they know how to get up and serve themselves water if need be. Staff reported that R1 was always encouraged to eat and drink and to let staff know if they needed anything. R1 verified this report. No other issues were reported until R1 was observed to be lethargic on August 27, 2025. Staff called 911 and R1 was transported to the hospital and admitted for Acute cystitis without hematuria (UTI). R1 was at the hospital from August 27, 2025, to September 5, 2025, and then discharged to a SNF on September 5, 2025. R1 was at the SNF until October 1, 2025, when they returned to the facility. The Administrator reported that they were unaware of R1 not ambulating prior to their hospitalization in August 2025. 2 out of 2 staff interviewed reported that R1 was able to ambulate on their own prior to August 27, 2025. R1’s emergency contact reported they were notified when R1 was hospitalized. R1 reported that if they wanted to move around or stay in their room, they can do what suits them. None of the evidence gathered supports the allegation. Based on the evidence gathered through interviews and documents reviewed the allegation is deemed Unsubstantiated, meaning that, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2026
LIC9099 (FAS) - (06/04)
Page: 3 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
09/23/2025 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250923153556

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: 110DATE:
07/15/2026
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Eric Vaca, Maria DimacaliTIME COMPLETED:
10:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not safeguard residents personal belongings
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the complaint investigation into the allegation listed above. LPA met with the Administrator Maria Dimacali the Director of Operations Eric Vaca and explained the reason for the visit.

The investigation into the allegation, staff did not safeguard residents personal belongings, revealed the following. It was reported that R1’s medical equipment and other person belongings were missing, such as, Dentures, two pairs of orthopedic shoes, walker, personal affects including all toiletries and most of R1’s clothing when they were at the hospital and Skilled Nursing Facility (SNF) from August 27, 2025, until October 1, 2025. R1’s emergency contact reported that on September 21, 2025, they went to get some of R1’s belongings so they could have them at the SNF. A review records shows that R1 had 2 property inventory sheets.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2026
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 5
Control Number 22-AS-20250923153556
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: 07/15/2026
NARRATIVE
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The first property list/inventory is dated January 1, 2024, and the property sheet dated September 21, 2025, showing what items R1’s emergency contact removed from the facility to take to R1 who was in at SNF at the time. R1’s emergency contact removed from the facility 2 pants, 2 shirts and 1 sweater. R1’s emergency contact signed and dated the form and there was a photocopy of their ID with the form. R1’s original property inventory sheet lists the following, 2 walkers, clothes, 5 jackets, bra, 3 socks and jogging pants. Nothing else is listed. The form is dated January 1, 2024. Dentures, shoes, personal effects and toiletries were not listed on the property inventory list. During the initial 10-day visit on September 25, 2025, the Administrator showed R1’s personal belongings box, which included dentures in their case, various clothing items, toiletries and 2 pairs of shoes and R1’s 2 walkers which were in their room, to LPA Alejandre. LPA observed all of R1's property in a box at the facility. The Administrator reported that they showed R1’s emergency contact R1’s property and they chose to only take clothing items. R1’s emergency contact reported they only took the items R1 requested and don’t remember seeing the other items. The Administrator reported that R1's items are kept secured at the facility. Based on evidence gathered the allegation, is Unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of the report provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5