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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006295
Report Date: 12/09/2025
Date Signed: 12/09/2025 11:54:20 AM

Unfounded


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
12/08/2025 and conducted by Evaluator RoseMarie Ruppert
COMPLAINT CONTROL NUMBER: 22-AS-20251208103650
FACILITY NAME:SENIOR FAMILY HOME 1FACILITY NUMBER:
306006295
ADMINISTRATOR:AGUSTIN, REYNALDOFACILITY TYPE:
740
ADDRESS:3148 W ROME AVENUETELEPHONE:
(714) 600-6195
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:6CENSUS: 5DATE:
12/09/2025
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Reynaldo Agustin, AdministratorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff are not distributing resident's medications as prescribed
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 was greeted and granted entry by Staff #1 (S1) and met with Administrator (AD) Reynaldo "Al" Agustin regarding the purpose of the visit.

LPA reviewed and obtained the following documents: Resident #1 (R1's) Medical Assessment, dated 12/05/2025 and hospital medical records. LPA also obtained a resident roster and additional documents for Resident #2 (R2) which include: face sheet and Medical Assessment dated 10/8/2025.

On Saturday, December 6 2025, R1 moved into the facility at 1:02pm from the hospital. R1 had a scheduled appointment with their primary care physician (PCP) on December 8, 2025 at 10:30am. The Power of Attorney (POA) requested for a staff member to accompany R1 to the appointment and AD agreed to go with R1. Transportation was coordinated with a private vendor by R1's medical provider.
(Continued on LIC 9099-C
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2025
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 2
Control Number 22-AS-20251208103650
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: SENIOR FAMILY HOME 1
FACILITY NUMBER: 306006295
VISIT DATE: 12/09/2025
NARRATIVE
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(Continued from LIC 9099)

While AD and R1 were in transit to PCP appointment, POA arrived at the facility and asked for R1's whereabouts and medications. Medications were counted and POA then left to meet R1 and AD at the PCP appointment at 10:30am. While at the appointment, POA told AD that POA would handle the PCP appointment and so AD, took the scheduled transport back to the facility. AD later learned from staff that R1 and POA returned to the facility after the appointment and packed R1's belongings and left. AD attempted to communicate with POA regarding why R1 was being moved but was unable to speak with POA. R1 resided at the facility less than 48 hours.

LPA interviewed two of two staff members if Staff are not distributing resident's medications as prescribed. Two of two staff members denied this allegation. LPA interviewed two of two alert residents if medications were not being given as prescribed. Two of two residents denied this allegation. LPA interviewed one witness who could not confirm, nor deny allegation and had never met R1.

LPA reviewed R1's Medical Assessment from 12/5/2025. R1 has diagnoses of: Family stress, hypertension, hypothyroidism and mild cognitive impairment with unknown etiology, as well as mild anxiety disorder. Per assessment, R1 is unable to administer own prescription medications. While at the facility, LPA counted all of R1's medications that were left at the facility. LPA compared tablet counts to bottle quantities listed. Based on medication count, medications were being given as prescribed.

Based on LPA's record review, observations and interviews, the allegation that: Staff are not distributing resident's medications as prescribed is Unfounded. The allegation is false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted with Administrator (AD) Reynaldo "Al" Augustin and copy of the report and LIC 811, were provided to the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2