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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006295
Report Date: 08/04/2026
Date Signed: 08/04/2026 04:26:41 PM

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
07/30/2026 and conducted by Evaluator Jerome Haley
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20260730081104
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:
08/04/2026
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Reynaldo AgustineTIME COMPLETED:
04:40 PM
ALLEGATION(S):
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Staff admitted a resident without their consent.
Staff do not allow resident access to their phone.
Staff do not allow resident to have visitors of her own choosing.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jerome Haley made unannounced visit to begin the investigation into the complaint received July 30, 2026. LPA Haley was greeted by staff and explained the reason for the visit upon entry.

Regarding the allegation: Staff admitted a resident without their consent.

During the investigation it was discovered, Resident 1 (R1) was admitted to the facility December 12, 2023, after moving out of a larger Assisted Living (AL) facility. R1 was admitted by one of their children who has a Power of Attorney (POA). R1’s admission agreement was signed, initialed, and dated by R1’s POA on December 11, 2023. Record review confirmed R1 has a diagnosis of dementia. R1’s diagnosis was confirmed by two family members and two facility staff members, including Administrator Reyanaldo Agustine who claims R1’s dementia is severe.

Continued on LIC812C
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

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

DATE: 08/04/2026
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 2
Control Number 22-AS-20260730081104
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: 08/04/2026
NARRATIVE
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Regarding the allegation: Staff do not allow resident access to their phone.

During interviews it was discovered that R1 does not have a telephone. R1 does have an iPad, and it was observed on the charger in the residents bedroom. According to a family member of R1, they did try to provide a telephone for the resident; however, it was useless to R1. The family member explained that R1’s dementia got so bad, that R1 could no longer use the phone anymore. The family member explained that R1 would just continue to press numbers on the phone. Facility staff denied taking a phone from R1. During record review, LPA Haley reviewed R1’s personal property inventory and it did not list any cell phone.

Regarding the allegation: Staff do not allow resident to have visitors of her own choosing.

During the investigation it was discovered R1 is allowed to have visitors. A family member of R1 explained there are serious concerns with another family member of R1 who has come to visit R1 in the past. The family member explained some serious concerns about the other member of and explained there’s a restraining order against the other family member. Record review revealed a restraining order filed in Orange County Superior Court on September 23, 2025. LPA Haley received a copy of the court order.

Based on the information gathered during the investigation through interviews, document review, and observations, the allegations are deemed unfounded, meaning the allegations are false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

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

DATE: 08/04/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2