306006118-7-9-2026-22-AS-LMOA-DWJ6LB-20260731205405

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306006118
Report Date: 07/09/2026
Date Signed: 07/09/2026 04:11:09 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
04/28/2026 and conducted by Evaluator Edward Kim

COMPLAINT CONTROL NUMBER: 22-AS-20260428141306

FACILITY NAME:	HILLS OF SHAY DEL, THE		FACILITY NUMBER:	306006118
ADMINISTRATOR:	NEPOMUCENO, MARICEL		FACILITY TYPE:	740
ADDRESS:	5982 SHAY DEL PLACE		TELEPHONE:	(626) 827-9547
CITY:	YORBA LINDA	STATE: CA	ZIP CODE:	92886
CAPACITY:	6	CENSUS: 0	DATE:	07/09/2026
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Staff- Rosendo Carlo Ward		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Facility staff handled resident in a rough manner resulting in bruising

INVESTIGATION FINDINGS:

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On July 9, 2026, at 2:00 PM Licensing Program Analyst (LPA) Edward Kim conducted a subsequent complaint visit to deliver complaint investigation findings. LPA Kim met with Administrator (ADMIN) Heddymae Oyson and explained the purpose of the visit. ADMIN Oyson could not stay for the visit and stated that Staff Rosendo Carlo Ward could sign on behalf of the facility.

The investigation consisted of the following. LPA Kim toured the facility. LPA Kim reviewed and obtained copies of the following records for one Resident: Admission Agreement, Identification and Emergency Information, Physician's Report, Appraisal Needs and Services Plans, and other pertinent records. LPA reviewed and obtained the Personnel Record, Resident Roster, and other pertinent records. LPA Kim conducted interviews with six staff and one witness

The investigation revealed the following:
Continued on LIC9099C

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2026

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 4

Control Number 22-AS-20260428141306

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: HILLS OF SHAY DEL, THE	FACILITY NUMBER: 306006118
	VISIT DATE: 07/09/2026

NARRATIVE

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Allegation: Facility staff handled resident in a rough manner resulting in bruising
It is alleged that bruising on both wrists and upper arms that appeared consistent with grab marks from resident #1’s (R1) caregiver.

Based on interviews conducted, four out of six staff and one out of one witness corroborated the allegation. One out of six staff denied the allegation. One out of six staff and one out of one resident could not confirm or deny the allegation. On April 18, 2026, S5 and S6 stated they found the bruises prior to giving R1 a shower. They noticed the bruises and reported to the administrator. S6 stated that they notified R1’s responsible party, when they arrived to the facility on April 18, 2026. S3, S4, S5, and S6 stated that bruises were found on R1’s left and right wrists and upper arms. The bruising was due to caregivers grabbing or holding the resident in a rough manner.

S3 and S6 stated on April 11, 2026, there were no bruise marks on R1, but on April 18, 2026, there were bruise marks evident on R1's left and right wrists and left and right upper arm areas.. S3 stated S1 and S2 admitted to them that they handled the resident in a rough manner which led to the bruising. S1 stated the bruising most likely occurred on April 15, 2026. S1 stated that S1 and S2 attempted to transfer R1 back to bed from the toilet, but R1 was fighting with S1 and S2. In order to prevent a fall or any other incident they needed to hold R1 down on their arms and wrists. Witness #1(W1) stated that the bruises were most likely from April 15, 2026, and that in April, there were no evidence of the bruises prior when they visited on April 18, 2026. W1 stated they were told from a doctor R1 went through a traumatic event because there was evidence of bruises on the left and right wrists and left and right upper arms, and there was evidence of muscle strain on R1’s neck and upper back. W1 stated that the doctor stated the bruising and muscle strains indicate trauma and that R1 was handled a rough manner.

Based on record review, S3 and W1 provided photos of R1 that were taken on April 18, 2026. The bruises are located on both wrists and the upper arms of R1. They are a dark purple color. Medical record dated on April 23, 2026, stated that R1 had bruising on their left and right wrists and upper arms, muscle strain on the neck, and muscle strain on the upper back. Staffing records verified S1 and S2 worked on April 14, 2026, and April 15, 2026, and S6 worked on April 11, 2026, April 12, 2026, April 18, 2026, and April 19, 2026. Based on observation, on May 6, 2026, LPA verified that R1 had bruising on their left and right wrists and upper arm.

Continued on LIC9099C

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2026

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20260428141306

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: HILLS OF SHAY DEL, THE	FACILITY NUMBER: 306006118
	VISIT DATE: 07/09/2026

NARRATIVE

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Based on interviews, record review and observation, R1 was mishandled in a rough manner that led to bruises. While transferring R1, S1 and S2 handled the resident in a rough manner that led to bruises and muscle strains on their neck and upper back.

Therefore, based on LPA's observations, interviews, and the records reviewed, the preponderance of evidence standard has been met, therefore the following allegation: Facility staff handled resident in a rough manner resulting in bruising is deemed SUBSTANTIATED as per the California Code of Regulations, Title 22, Division 6, Chapter 8. A deficiency is being cited on the attached LIC9099D.

Exit interview was conducted, and a copy of the report, LIC9099D, LIC811, and the appeal rights were provided to Staff Rosendo Carlo Ward.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 22-AS-20260428141306

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: HILLS OF SHAY DEL, THE	FACILITY NUMBER: 306006118
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/09/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/23/2026 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	87464 (f)(1) Basic services shall at a minimum include. Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not evidenced by: Based on observation, interview, and record review, the licensee did not comply with the	1 2 3 4 5 6 7	Licensee stated they will ensure all staff are trained on how to transfer residents who have dementia and send proof of completed training and copy of the training material to CCLD via email to edward.kim@dss.ca.gov by POC due date July 9, 2026.
	8 9 10 11 12 13 14	section cited above. Resident #1 (R1) was handled in a rough manner on April 15, 2026, that led to bruises where their physical health, safety, or welfare were endangered. This poses/posed a potential health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2026

LIC9099 (FAS) - (06/04)

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