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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006195
Report Date: 04/08/2026
Date Signed: 04/08/2026 07:07:43 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
10/22/2024 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20241022102800
FACILITY NAME:WESTMINSTER TERRACEFACILITY NUMBER:
306006195
ADMINISTRATOR:CRISTINA MILLERFACILITY TYPE:
740
ADDRESS:7571 WESTMINSTER BLVDTELEPHONE:
(714) 891-6608
CITY:WESTMINSTERSTATE: CAZIP CODE:
92683
CAPACITY:152CENSUS: 115DATE:
04/08/2026
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Carmen GaliciaTIME COMPLETED:
06:35 PM
ALLEGATION(S):
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Staff did not provide resident records to residents authorized representative.
Staff did not provide all resident medications to residents authorized representative.
Staff did not provide adequate laundry services to resident in care.
Staff did not update resident's care plan as necessary.
Staff did not follow physician's orders regarding resident in care.
Staff did not safeguard the personal possessions of resident in care.
Staff did not respond to requests for communication from resident's responsible party.
Staff forced resident in care to take medications.
Staff did not provide adequate care and supervision as outlined in resident’s care plan.
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 Carmen Galicia and explained the reason for the visit.

The investigation into the allegation, staff did not provide resident records to residents authorized representative, revealed the following. It was reported that when Resident 1 (R1) moved out of the facility the Responsible Party requested the Physician Orders for Life-Sustaining Treatment (POLST) be given to them so they could provide it to the new facility R1 was moving to. The Wellness Director (WD) reported that they processed the discharge of R1 when they moved out of the facility and the Responsible Party did not request any documents including the POLST. The WD reported that the Responsible Party never provided the actual POLST, they provided a printout of a picture of the POLST even though the facility requested the original document. No evidence was provided to corroborate the allegation.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2026
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 8
Control Number 22-AS-20241022102800
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: 04/08/2026
NARRATIVE
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The Administrator reported that the Responsible Party did not request any documents from them. Based on the evidence gathered the allegation is unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur.

The investigation into the allegation, staff did not provide all resident medications to residents authorized representative, revealed the following. It was reported that when R1 moved out of the facility on October 18, 2024, the Responsible Party was not provided with all R1’s medications. No specific medications were named and the number of medications not provided was not reported. Staff 1 (S1) and the Wellness Director (WD) both reported that when R1 moved out of the facility the Responsible Party was provided with all of R1’s medications and medication list. A review of records shows there is no sign out sheet showing the medication was provided to R1’s responsible party. There is no regulation that requires a resident or responsible party to sign for their medication when they leave the facility. At the time of the 10-day visit Staff 1 reported and LPA verified that there were no medications for R1 at the facility. Based on the evidence gathered the allegation is unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur.

The investigation into the allegation, staff did not provide adequate laundry services to resident in care, revealed the following. It was reported that R1’s laundry was not being done, and dirty laundry was piled on the floor. No dates or times were provided. Staff 2 (S2) reported that laundry is done once a week for residents except for those who do their own laundry, S2 reported that if required laundry is done more frequently based on need. S2 reported that on a few occasions R1 took all of their laundry out of the hamper and put it in the corner or the closet. S2 reported that they always did R1's laundry and made sure they put it in the proper place. S2 reported staff do a good making sure all the residents' laundry is done regularly and the residents always have clean clothes to wear. Photographic evidence was provided showing a pile of clothes. The condition of the clothes, clean or dirty cannot be determined by the picture and it is unknown how or why the clothes were in a pile. Based on the evidence gathered the allegation is unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 22-AS-20241022102800
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: 04/08/2026
NARRATIVE
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The investigation into the allegation, staff did not update resident's care plan as necessary, revealed the following. It was reported that after the care plan meeting for R1 was held on July 11, 2024, the care plan was not presented to the Responsible Party until September 2024 and was not signed until September 26, 2024. The Wellness Director (WD) reported that after the care plan meeting the Responsible Party did not agree with all of issues on the care plan and wanted changes. The Administrator reported that the Responsible Party contacted them after the care plan meeting and wanted changes to the care plan because they wanted to move R1 into a facility that was part of the Assisted Living Waiver (ALW) program that had a memory care unit, and they wanted an updated care plan to help facilitate the move. The Administrator and WD reported that care plan reflected R1’s current condition and the best care possible for R1. The Responsible Party denied that report and stated that the facility failed to provide the care plan in a timely manner. An email from the Responsible Party to the facility sent on Saturday August 31, 2024, shows that the Responsible Party requested changes be made before they sign the new care plan. The care plan meeting was conducted, and neither side could agree until changes were made that were acceptable to both parties, this delayed the process. Therefore, the allegation is unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur.

The investigation into the allegation, staff did not follow physician's orders regarding resident in care, revealed the following. It was reported that when R1’s physician ordered a special diet for R1 that the facility did not follow the order. The Wellness Director (WD) reported that all orders must be provided by the doctor on a prescription order blank. The WD and Administrator reported that most special orders for residents are faxed in and are on a prescription form. An email was provided that shows R1’s Responsible Party sent the facility a PDF attachment reporting R1’s physician has ordered a special diet for R1. A review of the email dated August 13, 2024, and the attached document shows that a CMA (Certified Medical Assistant) reported that R1’s doctor has reviewed the message and has ordered a diet rich in iron because of anemia. The document provided does not have any type of signature and it is not clear if R1’s physician wrote the text of the message. LPA reviewed orders for special diets and medications, all the other orders were provided on prescription orders, electronically (email) or faxed in with clear instructions and signatures. None of the evidence gathered supports the allegation. Therefore, the allegation is unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 22-AS-20241022102800
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: 04/08/2026
NARRATIVE
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The investigation into the allegation, staff did not safeguard the personal possessions of resident in care, revealed the following. It was reported that R1’s personal items, cell phone, tennis bracelet, prescription glasses and a State of California Disabled Person Parking Placard went missing because the facility did not safeguard R1’s possessions. The cell phone was reported missing on August 19, 2024, and was last seen by the Responsible Party on July 12, 2024. The 3 other items were reported missing on October 19, 2024, after R1 moved out of the facility. A review of records shows that the Responsible Party for R1 signed a form dated August 1, 2023, declining R1’s personal items to be inventoried and tracked. The WD reported that after the report, staff were instructed to look for the lost cell phone, but it was not located and R1’s Responsible Party was notified. The Responsible Party reported that none of the missing items were ever located. The WD reported that when the other items were reported missing staff checked R1’s former room but the items reported missing were not found, but staff found a gold watch and a butterfly pendant. The Administrator reported that they contacted the Responsible Party, but they never responded. The WD reported that they followed the theft and loss policy and communicated with the Responsible Party but they never acknowledged their messages. Based on the evidence gathered the allegation is unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur.

The investigation into the allegation, staff did not respond to requests for communication from resident's responsible party, revealed the following. It was reported that the facility did not regularly respond to calls or emails concerning R1 while they lived at the facility. The Administrator and WD reported that they regularly communicated with R1’s Responsible Party via email and phone messages. The Responsible Party reports they were not regularly called about anything concerning R1. The Administrator reported that any incident and any issues regarding care were addressed and were communicated to R1’s Responsible Party. California Code of Regulation (CCR) 87211 (a)(1) states, “A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below.” Item “D” of the regulation states, “Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.” The Administrator reported that the facility complies with all reporting requirements concerning all residents. The WD reported that R1’s Responsible Party was notified concerning any issues, especially incidents requiring a report as stated in CCR 87211.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 22-AS-20241022102800
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: 04/08/2026
NARRATIVE
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R1’s Responsible Party verified they were notified when R1 had to go to the hospital and concerning any mediation changes and falls. Based on the evidence gathered the allegation is unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur.

The investigation into the allegation, staff forced resident in care to take medications, revealed the following. It was reported that after R1 returned from a hospital visit on July 3, 2024, R1 was forced to take multiple antibiotics for 3 days. A review of records shows that R1 was sent to the hospital on or around July 3, 2024, for a urinary tract infection and a head injury from a fall. R1 returned the same day. The only medication change listed in the hospital discharge paperwork is Ciprofloxacin 500 mg. The attending physician at the hospital prescribed Ciprofloxacin 500 mg 2 times a day for 7 days for R1. R1 was already prescribed Levaquin. It was reported that in response to R1’s new prescription of Ciprofloxacin 500 mg R1’s physician ordered Levaquin to be discontinued and Macrobid to be started on July 3, 2024. A review of records shows R1’s physician faxed an order to the facility on July 5, 2024. The WD reported that once they received the discontinuance order they stopped administering the medication in question. The WD reported that they had been in communication with R1’s doctor and R1’s Responsible Party concerning the medication changes. The WD reported that the new medication was received on July 6, 2024. The WD reported that they can’t just stop or start any medications unless there is a doctor’s order and the facility had to wait for R1’s doctor to make the changes before they could take action. Based on the evidence gathered the allegation is unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur.

The investigation into the allegation, staff did not provide adequate care and supervision as outlined in resident’s care plan revealed the following. It was reported that R1 did not receive assistance regarding putting on their glasses and hearing aids and being escorted to all meals. It was reported that R1 was not checked on every 2 hours as outlined in their care plan. It was reported that R1 would not always have their hearing aids in or have their glasses on. 5 out of 5 staff interviewed reported that many residents including R1 remove their glasses and hearing aids during the day and don’t like using them.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 22-AS-20241022102800
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: 04/08/2026
NARRATIVE
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A review of records shows R1’s most recent care plan dated September 26, 2024, states R1 needs no assistance with their glasses and self manages putting on their glasses. The care plan shows R1 requires moderate assistance with their hearing aid, R1 needs to be reminded to use their hearing aids. The care plan shows R1 needs to be reminded to go to meals. It was reported that when R1 returned from a hospital visit on June 15, 2024, at 8:00 pm, which caused them to miss dinner and they were not fed until the next day at lunch time. A review of records shows that R1 went to the hospital on June 8, 2024, and returned to the facility on June 15, 2024, at 6:00 pm. Staff reported that when residents return from the hospital, they ask them if they have eaten and if they haven’t the staff will get the resident food. 4 out of 4 staff interviewed reported they do not remember any incidents with R1 and don’t remember R1 ever missing a meal unless they were at the hospital. 4 out of 4 staff interviewed reported that R1 was checked regularly as per the care plan when they were not in the hospital. R1 moved out of the facility on October 18 to a new facility and their location is unknown. 4 out of 4 staff interviewed denied the allegation. No evidence was gathered to support the allegation, therefore the allegation is unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that 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: 04/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 8
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
10/22/2024 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20241022102800

FACILITY NAME:WESTMINSTER TERRACEFACILITY NUMBER:
306006195
ADMINISTRATOR:CRISTINA MILLERFACILITY TYPE:
740
ADDRESS:7571 WESTMINSTER BLVDTELEPHONE:
(714) 891-6608
CITY:WESTMINSTERSTATE: CAZIP CODE:
92683
CAPACITY:152CENSUS: 115DATE:
04/08/2026
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Carmen GaliciaTIME COMPLETED:
06:35 PM
ALLEGATION(S):
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Staff did not ensure that resident was provided a clean environment while in care.
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 Carmen Galicia and explained the reason for the visit. The investigation into the allegation, staff did not ensure that resident was provided a clean environment while in care, revealed the following. It was reported that R1’s room was not kept clean, there was dust and small debris on R1’s floor. Staff reported that R1’s room was cleaned weekly and kept clean. The Administrator reported that anytime a resident or Responsible Party requests additional cleaning staff accommodate the request. Photographic evidence was provided showing R1’s floor. The picture shows dust and small debris on R1’s floor. Staff reported that deep cleaning is not done weekly but as needed. The picture of R1’s floor shows R1’s floor was not clean. The preponderance of evidence standard has met; therefore, the allegation is substantiated. Deficiencies are being cited per Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of the report provided along with appeal rights.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 22-AS-20241022102800
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/15/2026
Section Cited
CCR
87303(a)
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The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not being met as evidenced by, Photographic evidence shows R1's floor in their room was not clean.
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Licensee agrees to train housekeeping staff on CCR 87303 and to maintain all resident rooms in compliance with CCR 87303.
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This poses a potential health, safety and personal rights 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: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2026
LIC9099 (FAS) - (06/04)
Page: 8 of 8