306006195-2-6-2026-22-AS-APAO-DRL4JZ-20260223180934

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306006195
Report Date: 02/06/2026
Date Signed: 02/06/2026 01:07:39 PM

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
01/30/2026 and conducted by Evaluator Michael Tea

COMPLAINT CONTROL NUMBER: 22-AS-20260130122738

FACILITY NAME:	WESTMINSTER TERRACE		FACILITY NUMBER:	306006195
ADMINISTRATOR:	CARMEN GALICIA		FACILITY TYPE:	740
ADDRESS:	7571 WESTMINSTER BLVD		TELEPHONE:	(714) 891-6608
CITY:	WESTMINSTER	STATE: CA	ZIP CODE:	92683
CAPACITY:	152	CENSUS:	DATE:	02/06/2026
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Carmen Galicia		TIME COMPLETED:	01:25 PM

ALLEGATION(S):

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- Staff did not follow doctor's orders
- Staff mismanaged resident's medications
- Staff did not administer resident medication as prescribed

INVESTIGATION FINDINGS:

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On this day, Licensing Program Analyst (LPA) Michael Tea made an unannounced visit to conduct a complaint investigation. LPA Tea was greeted and granted entry by Executive Director (ED) Carmen Galicia and explained the reason for the visit.

The department received a complaint on January 30, 2026, and LPA Tea conducted the initial 10-day visit a week later on February 6, 2026. LPA Tea spoke to residents and facility staff and reviewed and collected pertinent documents and information.

It was alleged that staff did not follow doctor’s order. The investigation determined the following: The facility received a physician’s order indicating that Resident 1 (R1) was to self-administer medication. Executive Director (ED) Carmen Galicia and Health & Wellness Director (HWD) Veronica Mata
(Complaint Investigation continued on LIC9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20260130122738

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: WESTMINSTER TERRACE	FACILITY NUMBER: 306006195
	VISIT DATE: 02/06/2026

NARRATIVE

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acknowledged receipt of this order. However, the Physician’s Report dated December 16, 2025, indicated that R1 was unable to manage their own medications, with a side notation stating “certain medications.”

ED Galicia and HWD Mata explained that R1’s primary physician later submitted an updated Physician’s Report dated February 3, 2026, revising the assessment to reflect that R1 is able to administer and manage their medications independently. ED Galicia reported that the facility awaited clear clarification regarding medication management responsibilities due to the conflicting documentation. Additionally, R1 had expressed a preference to self-administer one medication while having the facility manage the remainder; however, the physician ultimately ordered that R1 could self-administer all medications.

As of February 5, 2026, with the updated Physician’s Report and physician’s order on file, R1 has been self-administering medications.

LPA interviewed five staff members; all five stated that they follow physician orders and cannot administer medications without written authorization or clarification. Staff reported that all medication administration requires documented physician direction.

LPA also interviewed four residents regarding medication management. Three residents stated that the facility follows physician orders. One resident reported waiting for clarification on their own orders but acknowledged understanding the need for physician authorization and clarification.

It was alleged that staff mismanaged resident’s medications The investigation determined the following: Five out of five staff interviewed stated that the facility does not mismanage medications. Staff explained that medications are administered within an accepted one-hour grace period before or after the scheduled time, consistent with standard practice, and that residents are informed of this administration window.

Staff reported that delays may occasionally occur due to the volume of residents requiring medication assistance; however, they stated that doses are not skipped or missed and that all administration is documented on the Medication Administration Record (MAR). Staff also indicated that residents sometimes refuse medications, which is documented accordingly.
(Complaint Investigation continued on LIC9099C)

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2026

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20260130122738

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: WESTMINSTER TERRACE	FACILITY NUMBER: 306006195
	VISIT DATE: 02/06/2026

NARRATIVE

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ED Galicia reported an instance in which R1’s medications on hand did not match the physician’s order; therefore, staff could not administer the medication until the discrepancy was resolved. MAR documentation reflected occasions when R1 was not present in the community or declined to wake at the scheduled administration time.

LPA interviewed four residents. One resident stated there was no medication mismanagement. Other residents expressed concerns about medications not being given exactly on the scheduled time or about last-minute reordering; however, they acknowledged staff workload and confirmed medications were generally received within the one-hour grace period. One resident emphasized the importance of timely medication due to medical conditions but did not report missed doses.

It was alleged that staff did not administer resident medication as prescribed. The investigation determined the following: All five staff interviewed stated that medications are administered exactly as prescribed, following physician orders regarding dosage, timing, and instructions. One staff member specifically noted that residents receive the precise dosage ordered.

LPA interviewed four residents, all of whom reported that staff administer medications as prescribed. Residents stated that dosages are provided correctly and generally within the appropriate timeframes. Examples included morning medications being administered in the morning and the correct number of pills being provided per physician direction.

Some residents expressed concern about the proximity of certain dosage times and felt the facility should continue monitoring scheduling closely; however, no resident reported receiving incorrect dosages or medications inconsistent with physician orders.

Therefore, based on LPA Tea's observations and interviews conducted and records reviewed the allegations mentioned above have been determined to be UNSUBSTANTIATED meaning that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

No deficiencies cited at this time and an exit interview was conducted with Executive Director Carmen Galicia. A copy of the report was provided to the facility.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2026

LIC9099 (FAS) - (06/04)

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