306006403-5-13-2026-22-AS-AORZ-DURVGA-20260605162512

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306006403
Report Date: 05/12/2026
Date Signed: 05/13/2026 08:21:16 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
02/12/2026 and conducted by Evaluator Samer Haddadin

COMPLAINT CONTROL NUMBER: 22-AS-20260212114138

FACILITY NAME:	ENDOR CARE HOME		FACILITY NUMBER:	306006403
ADMINISTRATOR:	DIXON, MITRA		FACILITY TYPE:	735
ADDRESS:	760 S. FAIRWAY LANE		TELEPHONE:	(714) 300-9512
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92807
CAPACITY:	6	CENSUS: 3	DATE:	05/12/2026
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	DSP Elizabeth Jones.		TIME COMPLETED:	11:43 AM

ALLEGATION(S):

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Staff did not administer medication as prescribed by the client's physician

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced visit to the facility to deliver findings regarding the allegation that “Staff did not administer medication as prescribed by the client’s physician.” Upon arrival, LPA Haddadin was greeted by Direct Support Professional (DSP) Elizabeth Jones., who granted entry. LPA explained the purpose of the visit. At the time of the visit, there were three clients in care. One client was attending day program, and two clients were present at the facility. During the course of the investigation, LPA obtained and reviewed relevant records and conducted staff interviews. It was alleged that staff did not administer medication as prescribed by the client’s physician. LPA interviewed the Licensee, who is also a Medical Doctor. The Licensee stated that Client 1’s (C1’s) prescription dosage needed to be updated because C1 was exhibiting increased agitation and behavioral concerns. The Licensee stated that she was unable to get in contact with C1’s current treating physician and further stated that she updated and made changes related to C1’s prescription.
{***CONTINUE9099C***}

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20260212114138

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: ENDOR CARE HOME	FACILITY NUMBER: 306006403
	VISIT DATE: 05/12/2026

NARRATIVE

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LPA also conducted one staff interview. The staff member stated they had no knowledge regarding the allegation. LPA attempted to interview the two clients who were present at the facility; however, LPA was unable to obtain reliable statements due to the clients’ cognitive abilities.
Based on interviews and record review, the Licensee made changes related to C1’s prescription without documentation showing approval from C1 or C1’s current treating physician. Although the Licensee is also a Medical Doctor, the Licensee was acting in the capacity of the facility Licensee at the time C1 was receiving care and supervision from the facility. As the Licensee, the responsibility was to ensure that medications were administered as prescribed and to seek proper clarification or direction from C1’s current treating physician when a medication concern arose. The Licensee exceeded the appropriate scope of facility authority by independently making changes related to C1’s prescription rather than following the existing physician’s order or obtaining documented authorization from C1’s treating physician. The Licensee’s action interfered with C1’s right to participate in decisions regarding their care.
Based on the preponderance of evidence gathered through interviews and record review, the allegation that “Staff did not administer medication as prescribed by the client’s physician” has been met. Therefore, the allegation is deemed SUBSTANTIATED.
The facility is being cited under Title 22, Division 6, California Code of Regulations, Section 80072(a)(1), Personal Rights.
An exit interview was conducted with DSP Elizabeth Jones. A copy of this report, Appeal Rights, and LIC 811, Confidential Names List, were provided at exit.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2026

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20260212114138

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: ENDOR CARE HOME	FACILITY NUMBER: 306006403
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/12/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/22/2026 Section Cited CCR 80072(a)(1)	1 2 3 4 5 6 7	80072(a)(1)80072(a)(1) Personal Rights Each client shall have personal rights which include, the right to be accorded dignity in personal relationships with staff and other persons.This requirement was not met as evidenced by	1 2 3 4 5 6 7	The Licensee shall submit written verification from C1’s assigned physician confirming C1’s current medication orders. The Licensee shall submit a signed staff training sheet showing
	8 9 10 11 12 13 14	Based on interviews and record review, the Licensee failed to ensure Client 1 (C1) was accorded dignity and respect when the Licensee acted outside the scope of her duties by making changes related to C1’s prescription without approval from C1 or C1’s current assigned physician. This poses potential personal rights, health, and safety risk to clients in care.	8 9 10 11 12 13 14	all staff were trained on client personal rights, medication order requirements, and scope-of-duty limitations. POC to be sent ti LPA by POC due date
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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: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2026

LIC9099 (FAS) - (06/04)

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