306006563-6-15-2026-22-AS-KSGH-DVJUQC-20260630154655

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306006563
Report Date: 06/15/2026
Date Signed: 06/15/2026 03:09:29 PM

Unsubstantiated

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
04/22/2026 and conducted by Evaluator Garlli Tat

COMPLAINT CONTROL NUMBER: 22-AS-20260422124146

FACILITY NAME:	SERENE HAVEN ASSISTED LIVING MISSION VIEJO		FACILITY NUMBER:	306006563
ADMINISTRATOR:	DAELTO, VEAHLOU		FACILITY TYPE:	740
ADDRESS:	26751 VIA GRANDE		TELEPHONE:	(714) 747-4537
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 3	DATE:	06/15/2026
		UNANNOUNCED	TIME BEGAN:	02:32 PM
MET WITH:	Adrian Manliclic		TIME COMPLETED:	03:20 PM

ALLEGATION(S):

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Resident sustained injuries due to physical abuse.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Garlli Tat made an unannounced visit to the facility to deliver the findings on the above allegation. LPA met with the caregiver Adrian Manliclic and explained the purpose of the visit. LPA left a voicemail for Administrator Genaro Salvador to inform them of the visit.

During the investigation, LPA inspected the facility, interviewed staff and residents, and reviewed records, including staff roster, resident roster, Resident 1’s (R1) Physician’s Report dated March 6, 2026, R1’s durable power of attorney for health care dated February 25, 2026, R1’s admission agreement dated March 17, 2026, R1’s transfer report, R1’s progress notes, R1’s pre-admission evaluation, and R1’s Physician Orders for Life-Sustaining Treatment (POLST).

The investigation into the allegation, resident sustained injuries due to physical abuse, revealed the following.
Continued on LIC 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Garlli Tat
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2026

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-20260422124146

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: SERENE HAVEN ASSISTED LIVING MISSION VIEJO	FACILITY NUMBER: 306006563
	VISIT DATE: 06/15/2026

NARRATIVE

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It was reported that R1 sustained an abrasion on their lip and bruising on their face as a result from physical abuse from staff. R1 moved to the facility on March 17, 2026, and moved out of the facility on April 23, 2026. R1 was admitted to the facility on Hospice. R1’s Physician’s Report dated March 6, 2026, shows R1 was diagnosed with Dementia and Traumatic subarachnoid hemorrhage. It was reported on April 20, 2026, that Home Health Worker (HHW) observed redness to R1’s right cheek and they informed the Hospice Company. HHW did not respond to LPA’s request for an interview. It was also reported that the Case Manager for R1 observed redness on R1’s cheek on April 20, 2026. LPA interviewed the Case Manager who reported that they have never witnessed any type of abuse at the facility and that the redness on R1’s face could have been caused by R1 falling asleep with their face on the oxygen tube. R1’s Responsible Party reported they saw R1 on April 21, 2026, and saw a red mark on their cheek and a mark outside of their upper left lip. R1’s Responsible Party reported their concerns to R1’s Hospice Company. R1’s Responsible Party reported that another Family Member reported R1’s upper lip was cut and had bruising on their eye; no date was provided as to when this was observed. LPA attempted to contact this Family Member, but they did not respond to LPA’s request for an interview so this report could not be verified. LPA interviewed R1. R1 reported that a female staff member hit them. R1 did not provide any other relevant information. All the current staff members at the facility are male, including the administrator. No female staff members worked at the facility during R1’s time at the facility. LPA conducted the initial 10-day visit on April 22, 2026. LPA did not observe any injuries on R1. LPA noted that R1 had dried lips and no red marks. Resident 2 (R2) and Resident 3 (R3) reported they have never seen staff or nurses hit residents. Resident 4 (R4) did not respond to LPA’s questions. Three out of three staff interviewed, including the Administrator, stated that they have never hit or abused R1 or any resident. The evidence gathered from the witnesses interviewed and from observations made during the initial 10-day visit are conflicting. There is no physical evidence that R1 suffered any injuries.

Therefore, based on the evidence gathered the allegation is deemed Unsubstantiated, meaning that although the allegation may have happened or is valid there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted with an authorized representative and a copy of this report, (LIC9099) was provided to the facility representative.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Garlli Tat
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2026

LIC9099 (FAS) - (06/04)

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