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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006133
Report Date: 07/30/2025
Date Signed: 07/30/2025 04:09:40 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
09/27/2023 and conducted by Evaluator RoseMarie Ruppert
COMPLAINT CONTROL NUMBER: 22-AS-20230927113557
FACILITY NAME:HILLS OF ROCKAWAY, THEFACILITY NUMBER:
306006133
ADMINISTRATOR:MEDINA, ALLENFACILITY TYPE:
740
ADDRESS:919 E ROCKAWAY DRIVETELEPHONE:
(909) 450-1699
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY:6CENSUS: 5DATE:
07/30/2025
ANNOUNCEDTIME BEGAN:
03:55 PM
MET WITH:Allen Medina, Maricel Nepomuceno and Keak VongphakdyTIME COMPLETED:
04:10 PM
ALLEGATION(S):
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The facility does not have sufficient resources to meet operating costs for care of residents.
INVESTIGATION FINDINGS:
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An office visit was scheduled on this day with Licensing Program Analyst (LPA) Rose Ruppert for the purposes of delivering findings into the above allegations. LPA met with Licensees Maricel Nepomuceno, Allen Medina and Keak Vongphakdy. It was alleged the facility does not have sufficient resources to meet operating costs for care of residents. The investigation determined as follows:

The Department conducted an audit of the facility finances based on the Licensee’s 2024 Monthly Operating Statement. Per the review of facility finances, withdrawals exceeded deposits by $8,440.57 in January of 2024 which indicate a net loss. The amounts reported on the LIC 401 could not be directly traced to the bank statements and additional support was not provided by the licensee, therefore, reasonable assurance could not be provided that the facility is generating income to cover operating expenses for January 2024. A review of the facility bills and monthly mortgage payment appeared to show payments were being made timely, however, bills requested for two months had failed to be provided.
(Continued on LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2025
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 3
Control Number 22-AS-20230927113557
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 ROCKAWAY, THE
FACILITY NUMBER: 306006133
VISIT DATE: 07/30/2025
NARRATIVE
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(Continued from LIC 9099)
Bank statements were reviewed from the dates of February 2023 through January 2024. Bank statement showed no late fees or Non-Sufficient Funds (NSF) check charges. The only fees that were noted on the statements were service fees or wire transfer fees, both inbound and outbound. Many online transfers were observed, including large lump sums. Based on many of the large transactions and consistent payments, it appears the licensee has large amounts of liabilities.

Therefore, based on records reviewed, it appears the licensee does not make sufficient income to cover operating expenses nor is there a sufficient cash reserve to cover operating expenses for one month. The licensee does not have a financial plan that complies with CCR Title 22 Section 87213, Finances. The allegation that facility does not have sufficient resources to meet operating costs for care of residents is deemed to be SUBSTANTIATED.

The following is being cited per California Code of Regulations, Title 22.

An exit interview was conducted with Maricel Nepomuceno, Allen Medina and Keak Vongphakdy and a copy of this report, LIC9099-D, and appeal rights was provided at the time of exit.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20230927113557
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 ROCKAWAY, THE
FACILITY NUMBER: 306006133
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/31/2025
Section Cited
CCR
87213
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87213 Finances. The licensee shall have a financial plan that conforms to the requirements of Section 87155, …that assures sufficient resources to meet operating costs for care of residents; may be required upon the written request of the licensing agency...
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The Licensees will self-certify understanding of financial requirements to operate facilities and send the statement and documentation to LPA by end of business, July 31, 2025. Licensees will update their financial plan for the long term to the Department as agreed per Non Compliance Conference (NCC).
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This requirement was not met as evidence by: Licensee did not ensure financial plan implemented ensured income to cover operating expenses nor maintain sufficient cash reserves to cover operating expenses. This poses an immediate 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: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3