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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006363
Report Date: 05/19/2026
Date Signed: 05/19/2026 03:06:30 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
03/14/2025 and conducted by Evaluator Andrea Mendivil
COMPLAINT CONTROL NUMBER: 22-AS-20250314094920
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: 12DATE:
05/19/2026
UNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Arya Maghboleh - Administrator TIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
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9
Staff verbally abused a resident while in care
Staff denied a resident from eating while in care
Staff did not follow general food service requirements
Resident sustained unexplained injuries while in care
Staff did not properly report incidents involving a resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the facility by staff and explained the reason for the visit.
The Department received a complaint on March 14 2025 and the initial visit was conducted on March 24th 2025. LPA Mendivil interviewed staff and residents and obtained copies of staff training records and resident physician reports. Regarding the allegations Staff verbally abused a resident while in care, Staff denied a resident from eating while in care, Staff did not follow general food service requirements , Resident sustained unexplained injuries while in care and Staff did not properly report incidents involving a resident the investigation revealed the following:

The facility consists of 2 homes sharing lot. The facility capacity is 15 and the current census is 12 residents.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2026
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 4
Control Number 22-AS-20250314094920
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: QUEENS HOME 3
FACILITY NUMBER: 306006363
VISIT DATE: 05/19/2026
NARRATIVE
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It was alleged that staff verbally abused resident while in care, per interviews with 6 out of 6 staff stated they have never verbally abused any resident in care. Based on interviews with 6 out of 6 residents interviewed stated no one has yelled at them. The remaining 6 residents were not available for interviews or not oriented to time and space.
It was alleged that staff denied a resident eating, per interviews with staff, 6 out of 6 staff stated they have never denied a resident food. Per interviews with 6 out of 12 residents stated they have never been denied food. 6 out of 6 residents interviewed stated the food is good and they have snacks available.
It was alleged that staff did not follow general food service requirements, per interview with Administrator Arya stated the facility has designated staff for cooking. LPA interviewed 6 out of 6 staff, staff stated they have never witnessed any issues with sanitation in the kitchen. Per LPA’s observation the kitchens are clean and free of debris and without odors.
It was alleged that resident sustained unexplained injuries while in care . Per review of Resident 1 (R1) physician report dated December 22 2024, R1 is diagnosed with dementia and has a history of skin breakdown. No photographs, medical records or documentation could be found to verify the presence of an injury for any resident in care. Interviews with 6 out of 6 staff, staff stated they have not been rough when handling any residents. Per interview with Administrator Arya, AD stated that R1 would rattle their bed rails and would hit against the bed rails. Based on 6 out of 6 residents interviewed, they stated that all the staff is kind and gentle and no one has been aggressive.
It was alleged that staff did not properly report incident involving residents. Per review of LIC 624 Unusual Incident/Serious Injury reports facility reported various incidents. Per staff interviewed, incidents were reported to facility Administrator. No further documentation of incidents was obtained to suggest incidents were not being reported as required.
Therefore based on the preponderance of evidence through records reviewed, interviews and observations the allegations Staff verbally abused a resident while in care, Staff denied a resident from eating while in care, Staff did not follow general food service requirements , Resident sustained unexplained injuries while in care and Staff did not properly report incidents involving a resident are determined to be UNSUBSTANTIATED, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.
No deficiencies are being cited in today's visit.
An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
03/14/2025 and conducted by Evaluator Andrea Mendivil
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250314094920

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: 12DATE:
05/19/2026
UNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Arya Maghboleh - Administrator TIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff left residents unattended
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the facility by staff and explained the reason for the visit.
The Department received a complaint on March 14 2025 and the initial visit was conducted on March 24th 2025. LPA Mendivil interviewed staff and residents and obtained copies of staff training records and resident physician reports. Regarding the allegation staff left residents unattended, the investigation revealed the following:

The facility consists of 2 homes sharing lot. The facility capacity is 15 and the current census is 12 residents.
It was alleged that staff left residents unatteneded. Per interviews with 6 out of 6 staff stated there is 1 overnight awake staff that is present.Administrator Araya stated that the overnight staff will attend to both homes. Administrator stated there are also live in staff that are available if needed. Per interviews with 6 residents, they stated awake staff comes into their rooms every 2 hours to check on them.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 22-AS-20250314094920
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: QUEENS HOME 3
FACILITY NUMBER: 306006363
VISIT DATE: 05/19/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
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15
16
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Therefore based on the preponderance of evidence through interviews the allegation that staff left residents unattended is determined to be UNFOUNDED, meaning that the allegations were 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: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 4