306006242-9-19-2025-22-AS-APAO-DLZW5U-20250930165943

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306006242
Report Date: 09/19/2025
Date Signed: 09/19/2025 03:55:00 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
08/13/2025 and conducted by Evaluator RoseMarie Ruppert

COMPLAINT CONTROL NUMBER: 22-AS-20250813133028

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:	01:30 PM
MET WITH:	Tonya Reynolds, Executive Director		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Resident sustained unexplained injuries while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to continue a complaint investigation. LPA met with Marisa Zamudio, Memory Care Director (MCD) and Tonya Reynolds, Executive Director (ED).

It is alleged that Resident #1 (R1) sustained unexplained injuries while in care. LPA reviewed the following documentation from Resident #1 (R1)'s file: Identification and Emergency Information, Physician's Report, and Needs and Services Plan. LPA also requested Care staff schedule from July 24-July 28, 2025, a staff roster with telephone numbers and additional documentation related to the incident that occurred during this time period. R1 has resided in the community and moved in on January 12, 2022. A medical assessment was done on March 27, 2025.

(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)

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Control Number 22-AS-20250813133028

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)

The facility submitted an Unusual Incident Report to the Department for an incident that was reported on July 28, 2025. It was reported to staff that Resident #1 (R1) had a swollen right hand and scratches under both eyes. Staff immediately called 911 for R1 o be taken to the hospital for further evaluation and contacted the Power of Attorney (POA). POA refused for resident to go to the hospital. Facility staff continued to document discoloration of R1's eye since R1 has a history of pink eye per LPA's review of facility progress notes. Per review of physician fax reports Nurse immediately contacted PCP for antibiotic drops with a physician phone order on July 28, 2025.

The Primary Care Physician (PCP) visited the next day, July 29, 2025 at 8am and mobile x-rays were ordered at 8:45am. X-ray results showed there were no fractures in hand. Per facility progress notes R1 was sent to the hospital for further assessment at approximately 1:07pm and returned at 5pm. Also on July 29, 2025 a meeting was held with Health Services Director, Memory Care Director and Business Office Director with Resident #1's POA and two other guests to address the incident. Facility stated they would continue to investigate and issues were unresolved at the conclusion of the meeting. On July 30, 2025 an internal investigation by the Regional team was conducted and no evidence was found to support allegation. Resident #1 (R1) moved out of the community on August 5, 2025.

On August 14th and August 21st, 2025, LPA conducted visits to request documentation. Over the course of the investigation LPA interviewed five of five witnesses. Three of the five witnesses confirmed the allegation that R1 sustained unexplained injuries while in care. Two of the five witnesses denied the allegation. LPA interviewed four of four residents regarding staff and the quality of care provided. Four of four residents confirmed they are being cared for. LPA interviewed six of six staff members regarding the incident. Six of six staff members denied the allegation.

Based on LPA file review, observations and interviews, although the allegation my 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: Resident sustained unexplained injuries while in care is Unsubstantiated.

An exit interview was conducted with Tonya Reynolds, Executive 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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