306006406-7-29-2026-22-AS-SSAS-DWHTS6-20260731145838

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306006406
Report Date: 07/29/2026
Date Signed: 07/29/2026 12:21:07 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
07/24/2026 and conducted by Evaluator Brandon Lopez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20260724150920

FACILITY NAME:	HILLS OF BROADWAY, THE		FACILITY NUMBER:	306006406
ADMINISTRATOR:	MIRANDA, ROSENDO C		FACILITY TYPE:	740
ADDRESS:	354 BROADWAY		TELEPHONE:	(714) 430-7672
CITY:	COSTA MESA	STATE: CA	ZIP CODE:	92626
CAPACITY:	6	CENSUS: 4	DATE:	07/29/2026
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Licensees Allen Medina & Maricel Nepomuceno via telephone		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Facility did not issue responsible party proper refund.

INVESTIGATION FINDINGS:

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On July 29, 2026, Licensing Program Analysts (LPAs) Brandon Lopez and Tran Nguyen made an unannounced visit to the facility to initiate the investigation into the allegation listed above and to deliver the complaint findings. LPAs were greeted and granted entry into the facility by staff after explaining the purpose for the visit. Licensees Allen Medina and Maricel Nepomuceno were notified via telephone but was unable to assist with today's inspection.

During the course of the investigation, LPAs conducted staff interviews, reviewed and obtained pertinent documents for this complaint. Regarding the allegation, facility did not issue responsible party proper refund, the following has been concluded: It was alleged that the facility did not issue responsible party proper refund for Resident #1 (R1). During the investigation, LPAs conducted a file review for R1, including R1's admission agreement. LPAs observed that R1 was admitted to the facility on May 2, 2025. LPAs observed that the admission agreement was signed by R1's Responsible Party, Witness #1 (W1), and a facility representative, indicating that both parties agreed to the terms of the admission agreement.
CONTINUED ON LIC9099-C

Substantiated

Estimated Days of Completion: 90

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2026

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-20260724150920

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: HILLS OF BROADWAY, THE	FACILITY NUMBER: 306006406
	VISIT DATE: 07/29/2026

NARRATIVE

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LPAs observed that on page five of R1's admission agreement, is states, "Per community policy, the admission agreement is automatically terminated on the date of the resident's death. The responsible party will not be responsible for any charges after the resident's date of death." On page five, it also states, "Within 3 days of the resident's death, the community shall send a copy of this admission agreement to serve as a reminder that the admission agreement terminates upon the resident's date of death and that no further payment is required and that there is no fee for storing the resident's property..". LPAs conducted an interview with R1's responsible party, W1. W1 stated that R1's rent was paid in full for the month of June 2025, which was in the agreed amount of $8,500.00. W1 stated that R1 passed away on June 7, 2025, and the facility did not issue them a refund for the remaining twenty three days of June 2025, as agreed upon in the admission agreement. W1 stated that they are currently owed $6,516.59. W1 stated that they also sent the facility a demand letter to the Licensees on May 26, 2026, regarding the refund for R1, but that the they still has not issued them a refund. LPAs reviewed a bank statement that confirmed that W1 made a payment in the amount of $8,500.00 for R1's monthly rent for June 2025. LPAs also reviewed the certificate of death for R1 which confirmed that R1 passed away on June 7, 2025. LPAs conducted an interview with Licensee Maricel Nepomuceno. The Licensee admitted that a refund had not been issued to W1 after R1 passed away on June 7, 2025. The Licensee confirmed that W1 is currently owed the remaining twenty three days for R1's June 2025 rent. The Licensee also confirmed that they also received the demand letter from W1 on May 26, 2026.

Based on the evidence gathered during this investigation, the Department obtained sufficient evidence to substantiate the allegation that, facility did not issue responsible party proper refund. The preponderance of evidence standards has been met; therefore, the above allegation is SUBSTANTIATED. A deficiency is being cited on the attached LIC9099-D. An exit interview was conducted via telephone with Licensee Maricel Nepomuceno. A copy of the report and appeal rights were provided to an authorized facility representative at time of visit.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2026

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20260724150920

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: HILLS OF BROADWAY, THE	FACILITY NUMBER: 306006406
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/29/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/07/2026 Section Cited CCR 87507(f)	1 2 3 4 5 6 7	87507 Admission Agreement: (f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement was not evidenced by:	1 2 3 4 5 6 7	The Licensee stated that they will issue a refund to Resident #1's responsible party for the remaining twenty three of June 2025. The Licensees agreed to provide LPA proof of the refund via email or fax by POC due date.
	8 9 10 11 12 13 14	Based on interviews conducted and records reviewed, the Licensee did not ensure that a refund was issued to Resident #1's responsible party after her death. This poses a potential health, safety, and personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2026

LIC9099 (FAS) - (06/04)

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