306006242-9-19-2025-22-AS-APAO-DLZVW5-20250930164722

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306006242
Report Date: 09/19/2025
Date Signed: 09/19/2025 12:16:11 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
09/10/2025 and conducted by Evaluator RoseMarie Ruppert

COMPLAINT CONTROL NUMBER: 22-AS-20250910161426

FACILITY NAME:	CAPRIANA		FACILITY NUMBER:	306006242
ADMINISTRATOR:	REYNOLDS, TONYA		FACILITY TYPE:	741
ADDRESS:	460 LA FLORESTA DRIVE		TELEPHONE:	(714) 985-5500
CITY:	BREA	STATE: CA	ZIP CODE:	92821
CAPACITY:	200	CENSUS: 142	DATE:	09/19/2025
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Tonya Reynolds, Executive Director and Marisa Zamudio, Memory Care Director		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff are not supervising residents resulting in resident-on-resident incidents.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to investigate a complaint received in the Regional Office. LPA met with Marisa Zamudio, Memory Care Director (MCD) and Tonya Reynolds, Executive Director (ED).

It was alleged that staff are not supervising residents resulting in resident-on-resident incidents. LPA reviewed the Unusual Incident Reports submitted to the Department on May 7, 2025 for an incident between Resident #1 (R1) and Resident #2 (R2). On May 28, 2025 LPA conducted a Case Management visit to follow-up with a similar incident with R2 and another resident. LPA reviewed R2's: Facesheets, Physician's Reports, Needs and Services Plans, Appraisals and documentation regarding follow-up care plan meetings and electronic files regarding behavior documentation. R2 has had a personal caregiver since May 6, 2025. R2 moved into the facility in March of 2025 from another community that did not have Memory Care.

(Continued on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2025

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-20250910161426

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: CAPRIANA	FACILITY NUMBER: 306006242
	VISIT DATE: 09/19/2025

NARRATIVE

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(Continued from LIC 9099)

On today's date LPA reviewed R1 and R2's Facesheets, Physician's Reports, Needs and Services Plans, Appraisals and facility progress notes. Per facility progress notes, at 8:45pm on Monday, May 5, 2025, a staff member reported that R2 had their hand in R1's pants in the common area. R1 was asleep during the incident. The Med Tech immediately called 911, as well as R1 and R2's Power of Attorneys (POA)s, regarding the incident. R1's POA arrived at the facility within twenty minutes and remained with R1 through bedtime. Local law enforcement arrived on-site and spoke with staff and Health and Wellness Nurse (HWN) at approximately 9pm.

The facility submitted an Unusual Incident Report with the Department on Tuesday, May 6, 2025. R1's POA met with Executive Director and HWN on May 6, 2025 to follow-up on the incident that occurred. On May 6, 2025, HWN spoke with R2's POA to follow-up with Primary Care Physician (PCP) regarding behavior. A private companion was recommended and a virtual appointment was scheduled with PCP at 3:30p on the same day. A private companion arrived at 2:30pm on May 6, 2025.

LPA conducted a health and safety check and toured the facility. LPA observed residents eating breakfast and participating in activities. LPA also interviewed six of six residents regarding care provided and if they have been inappropriately touched by either another resident or staff. Five of six interviewed denied this allegation. One of six interviewed confirmed this allegation.

LPA interviewed five of five staff members. Five of five staff confirmed that R2 has inappropriate behavior and a 24 hour personal companion arrived the day after the incident on May 5, 2025 occurred. Physician's Report for R2 does not document any behaviors. R2's Individualized Service Plan was updated on May 13, 2025 with a care plan meeting with R2's Power of Attorneys via telephone. Recently, R2's behaviors have stabilized and have been managed with medications. A personal companion remains from 8am to 8pm and R2 sleeps throughout the night. Staff continued to document R2's incidents in progress notes. LPA interviewed the LVN nurse and Med Tech who were present at time of incident. Staffing for the PM shift is the same as the day shift with one Med Tech and three caregivers per floor and one Nurse for the Villagio building. The incident took place in a common area and was immediately noted by staff.

(Continued on LIC 9099-C1)

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 22-AS-20250910161426

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: CAPRIANA	FACILITY NUMBER: 306006242
	VISIT DATE: 09/19/2025

NARRATIVE

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(Continued from LIC 9099-C)

Based on LPA's file review, observations and interviews, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore the allegation that: Staff are not supervising residents resulting in resident-on-resident incidents is Unsubstantiated.

An exit interview was conducted Marisa Zamudio,Memory Care Director and a copy of this report and LIC 811 was provided to the facility.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2025

LIC9099 (FAS) - (06/04)

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