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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006280
Report Date: 07/15/2026
Date Signed: 07/15/2026 10:32:13 AM

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
03/05/2026 and conducted by Evaluator Eboni Bentley
COMPLAINT CONTROL NUMBER: 22-AS-20260305084042
FACILITY NAME:SHASTA RESIDENTIAL CAREFACILITY NUMBER:
306006280
ADMINISTRATOR:DINH, KEVIN DINOFACILITY TYPE:
740
ADDRESS:16274 SHASTA STTELEPHONE:
(714) 300-4540
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY:6CENSUS: 5DATE:
07/15/2026
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Kevin Dinh - Licensee/AdministratorTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff did not allow resident back into facility after hospitalization.
INVESTIGATION FINDINGS:
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On July 15, 2026, Licensing Program Analyst (LPA) Eboni Bentley arrived at the facility unannounced for a subsequent complaint investigation visit into the above allegation. LPA was greeted and granted entry after stating the purpose of the visit to staff. Licensee/Administrator Kevin Dinh was contacted and arrived shortly to assist with the visit.

Regarding the allegation: Staff did not allow resident back into facility after hospitalization.
During the course of the investigation LPA reviewed facility documents including: Resident Roster, Staff Roster, Physician's Report, Resident Medication Administration Record, and Hospital Medical Records. Interviews were conducted with residents, staff, and witnesses. On March 2, 2026, Resident #1 (R1) moved into the facility. A record review revealed, R1 was admitted to the hospital on March 3, 2026, due to refusal of medication and aggressive behaviors toward facility staff.

REPORT CONTINUES ON LIC9099-C….
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Eboni Bentley
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2026
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 3
Control Number 22-AS-20260305084042
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: SHASTA RESIDENTIAL CARE
FACILITY NUMBER: 306006280
VISIT DATE: 07/15/2026
NARRATIVE
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On March 5, 2026, the resident was scheduled to be discharged from the hospital, however, the facility refused to allow R1 to return. During an interview, Licensee/Administrator Kevin Dinh, stated “I have a right to refuse to take a resident back” and admitted that no written eviction notice was issued the resident.

Based on interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegation: Staff did not allow resident back into facility after hospitalization is deemed SUBSTANTIATED. A deficiency is being cited on the attached LIC 9099-D, as per Title 22, Division 6, Chapter 8 of the California Code of Regulations.

An exit interview was conducted with Administrator Kevin Dinh and a copy of this report, LIC9099-D, LIC811, and appeal rights were provided at the end of the visit.
SUPERVISORS NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Eboni Bentley
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20260305084042
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: SHASTA RESIDENTIAL CARE
FACILITY NUMBER: 306006280
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/16/2026
Section Cited
CCR
87224(a)
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87224 (a)Eviction Procedures -
The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty days written notice to the resident is required...This requirement was not met as evidenced by:
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Licensee/Administrator Kevin Dinh agrees to read and review regulation section 87224 Eviction Procedures, and send LPA Bentley a signed statement of acknowledgement and understanding by end of day on POC due date of July 16, 2026.
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Based on interview confirmation, Resident 1 (R1) was not allowed to come back to the facility after a visit to the hospital on May 5, 2026. R1 was discharged from the hospital May 5, 2026 and Licensee/Administrator stated to LPA that they do not have to accept the resident back.
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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: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Eboni Bentley
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2026
LIC9099 (FAS) - (06/04)
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