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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006363
Report Date: 09/03/2025
Date Signed: 09/03/2025 03:23:17 PM

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
04/16/2024 and conducted by Evaluator Jerome Haley
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240416145514
FACILITY NAME:QUEENS HOME 3FACILITY NUMBER:
306006363
ADMINISTRATOR:MAGHBOULEH, KATHYFACILITY TYPE:
740
ADDRESS:14752 HOLT AVETELEPHONE:
(714) 731-6385
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY:15CENSUS: 9DATE:
09/03/2025
UNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Arya MaghboulehTIME COMPLETED:
02:25 PM
ALLEGATION(S):
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Resident sustained unexplained injuries
Staff handled resident in a rough manner
The facility did not accurately report resident's injuries
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit to the facility to deliver findings on the allegations listed above. LPA was greeted and granted entry by staff after an introduction and stating the purpose of the visit.

The complaint investigation was initiated by LPA Jerome Haley on April 17, 2024, regarding complaint allegations filed on April 16, 2024. The complaint was investigated by the Department and consisted of the following: a tour of the physical plant, record review (resident & staff), and interviews with facility staff including Licensee/Administrator Kathy Maghbouleh, medical professionals, and a witness. Documents and photos were provided and reviewed including hospice records from Golden Coast Hospice and Palliative Care, and photos of Resident 1’s (R1) injuries.

During the investigation 7 of 7 individuals interviewed, including facility staff and medical professionals,
Continued on LIC9099C page 1 of 3
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
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 5
Control Number 22-AS-20240416145514
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: QUEENS HOME 3
FACILITY NUMBER: 306006363
VISIT DATE: 09/03/2025
NARRATIVE
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provided information that supports the complaint allegations.

During interviews, Registered Nurse 1 (RN1) confirmed they were notified on April 11, 2024, regarding a small skin tear on the right arm of R1. After responding to the facility, RN1 observed the smaller skin tear to the right arm, and an additional larger skin tear on R1’s left arm. RN1 explained, R1 sustained small skin tears before, but not to the degree of what R1 sustained on April 11, 2024. RN1’s medical opinion is that both skin tears occurred at the same time and were fresh. RN1 stated, it’s reasonable to believe the bruise observed on R1’s forehead was also sustained at the same time of the skin tears.

Per information gathered from Licensee – Kathy Maghbouleh (S10), on April 11, 2024, S1 was present in the facility when R1 sustained a small cut to the right arm. According to Licensee Maghbouleh, they helped put a bandage on the smaller cut to R1’s right arm. Licensee Maghbouleh claimed an unidentified caregiver told S1 the skin tear occurred during a transfer. The unidentified caregiver explained to Licensee Maghbouleh, that R1 has no muscle control and can easily lean forward while in the wheelchair and hit their head. Licensee Maghbouleh claims this is probably how R1 sustained the bruise on the forehead. The unidentified caregiver told Licensee Maghbouleh, they did not see the larger cut on the left arm, and suggested, maybe the hospice nurse who responded to the facility caused the cut on the left arm.

Per the information gathered from Witness 1 (W1), after R1 sustained unexplained cuts and bruises on April 11, 2024, W1 and Licensee Maghbouleh came to a verbal agreement. Licensee Maghbouleh allowed W1 to place a camera in R1’s room after the resident sustained “unexplained injuries.” Shortly after the camera was placed in the resident’s room, on April 14, 2024, a video was recorded that showed a caregiver handling R1 in an aggressive manner while changing the resident. The video recording of the caregiver (now Former Caregiver 1 – FC1) handling R1 was provided for review.

Per information provided by Staff 5 (S5), FC1 was unaware a surveillance camera was installed in R1’s room. FC1 was recorded changing R1’s diaper and flipped R1 like a piece of paper.

Licensee Maghbouleh confirmed the verbal agreement with W1 for a camera to be placed in R1’s room after R1 sustained injuries on April 11, 2024; furthermore, S1 (licensee) confirmed FC1 was terminated after the video recording that shows the former caregiver handling R1 in a rough manner.

Continued on LIC812C page 2 of 3
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 22-AS-20240416145514
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: QUEENS HOME 3
FACILITY NUMBER: 306006363
VISIT DATE: 09/03/2025
NARRATIVE
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During subsequent interviews to clear up discrepancies discovered during the investigation, three facility staff members including Licensee Maghbouleh admitted to providing false statements regarding the details of the fall that occurred on April 11, 2024. Licensee Maghbouleh, S3, and S6, all admitted R1 was found on the floor with a skin tear after being left alone in their wheelchair. Licensee Maghbouleh, S3, and S6, all admitted to providing false statements during previous interviews.

It was confirmed, not only were false statements provided to the department during the course of a complaint investigation, but a hospice nurse was falsely accused or "suggested" to be responsible for causing the larger skin tear to R1 when Licensee Maghbouleh, S3, and S6 all knew the statement and/or suggestion that the hospice nurse was responsible for the large skin tear was false.

Based on the evidence gathered through interview confirmation, document review, staff’s own admissions, and video review, the preponderance of evidence standard has been met, therefore, all three allegations listed above are found to be SUBSTANTIATED. Violations are being cited per California Code of Regulations Title 22, Division 6.

An immediate Civil Penalty is being assessed today in the amount of five hundred dollars ($500).
An additional Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49(f).

An exit interview was conducted, and a copy of this report and appeal rights were provided.



Page 3 of 3
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 22-AS-20240416145514
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: QUEENS HOME 3
FACILITY NUMBER: 306006363
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/04/2025
Section Cited
CCR
87464(f)(1)
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Basic Services
(f) Basic services shall at a minimum include:
(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).
Health and Safety Code section 1569.2(c) provides:
(c) "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with.., or personal care.
This requirement was not met as evidenced by:

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Administrator Maghbouleh stated the regulation will be reviewed by all Administrators and the Licensee. A signed statement of acknowledgement and understanding will be provided for each Administrator and the Licensee, for a total of four statements of acknowledgement. POC is by 4:00pm on the POC due date.
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Three staff members including Licensee Maghbouleh, confirmed R1 was left unattended, resulting in the resident falling and sustaining skin tears to both arms and bruising to the forehead. This poses a threat to the health, safety, and personal rights of residents in care.
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Type A
09/04/2025
Section Cited
CCR
87468.1(a)(1)
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Personal Rights of Residents in All Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following Personal Rights:
(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
This requirement was not met as evidenced by:
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Administrator Maghbouleh stated the regulation will be reviewed by himself, and all primary caregivers. A signed statement of acknowledgement and understanding will be provided for each primary caregiver.If all staff can not review the regulation with the licensee and sign a statement of acknowledgement and understanding. Licensee will be given no more than three business days to submit all signed statements.
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On April 14, 2024, a caregiver was recorded on video handling R1 in a rough manner. While being changed, R1 was carelessly flipped over by one of the caregivers. Multiple individuals, including Licensee Maghbouleh confirmed the now former caregiver’s actions captured on video. This poses a threat to the health, safety, and personal rights of residents in care.
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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: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20240416145514
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: QUEENS HOME 3
FACILITY NUMBER: 306006363
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/05/2025
Section Cited
CCR
87211(a)(1)
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Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.
This requirement was not met as evidenced by:
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Administrator Maghbouleh stated himself, and the other Administrator(s) and the licensee will read and review the regulation section on Reporting Requirements and send a signed statement of acknowledgement and understanding for each administrator and the licensee. AD Maghbouleh will conduct and in-service training for all staff members on reporting requirements and email the sign in sheet for all staff in attendance, and share with the department who the primary person and a secondary person responsible for sending all incident reports to the department in a timely fashion. POC is due Friday, September 5, 2025, by 1:00pm.
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The facility failed to accurately report R1’s falls and injuries to R1’s responsible person. The facility also failed to accurately report R1’s fall and injuries to the department. The incident report with no date contains false information and there’s no incident report for R1 from Queens Home 3 in the departments data base for all incident and death reports.
This poses a potential threat to the health, safety, and personal rights of residents
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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: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5