<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880782
Report Date: 01/30/2025
Date Signed: 01/30/2025 04:08:19 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/11/2024 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20241211094442
FACILITY NAME:MIMOSA HIGHPOINTEFACILITY NUMBER:
331880782
ADMINISTRATOR:STEWART, LEONAFACILITY TYPE:
735
ADDRESS:15160 MIMOSA DRTELEPHONE:
(562) 682-0946
CITY:LAKE ELSINORESTATE: CAZIP CODE:
92530
CAPACITY:4CENSUS: 4DATE:
01/30/2025
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:House Manager Maureen Sevilla and House Manager Charles OkojieTIME COMPLETED:
04:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff gave a medication to client without doctor's order
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 01/30/2025 at 02:00 PM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility to deliver the findings of the above allegation. LPA Brown explained the purpose of the visit to a staff. Staff contacted Administrator Adegboyega Agbulusi and informed of the visit. House Manager Maureen Sevilla and House Manager Charles Okojie arrived during the visit. LPA Brown explained the purpose of the visit to House Managers Sevilla and Okojie. The investigation consisted of file review, interviews with staffs and residents as well as observation.

The investigation was conducted by LPA Brown. The investigation consisted of file review, interviews with relevant parties and observation. The allegation indicates staff gave a medication to client without doctor's order. During the investigation, LPA Brown obtained evidence to corroborate the allegation. Interviews with Client #1 (C1) indicated that staffs at the facility are giving medications to C1 without a doctor's order.
Staff #1 (S1) confirmed with LPA Brown that it was reported to S1 that C1's four (4) medications were given without doctor's order and medication training was provided ***Continuation in LIC9099C***
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2024
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 56-AS-20241211094442
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: MIMOSA HIGHPOINTE
FACILITY NUMBER: 331880782
VISIT DATE: 01/30/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
to the staffs on 12/13/2024 by a licensed professional. During the facility visit on 12/16/2024, LPA Brown conducted a medication audit for C1 and Client #2 (C2) and observed that staffs at the facility are not assisting C1 and C2 with their medications as prescribed by their doctors. as evidenced of medications were given without doctor's order.

Based on observation, interviews, and documents review, the allegation of staff gave a medication to client without doctor's order is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted and a copy of this report, LIC9099, LIC9099D and appeal rights was discussed and provided to House Manager Maureen Sevilla and House Manager Charles Charles Okojie.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/11/2024 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20241211094442

FACILITY NAME:MIMOSA HIGHPOINTEFACILITY NUMBER:
331880782
ADMINISTRATOR:STEWART, LEONAFACILITY TYPE:
735
ADDRESS:15160 MIMOSA DRTELEPHONE:
(562) 682-0946
CITY:LAKE ELSINORESTATE: CAZIP CODE:
92530
CAPACITY:4CENSUS: 4DATE:
01/30/2025
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:House Manager Maureen Sevilla and House Manager Charles OkojieTIME COMPLETED:
04:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not keep the facility free from roaches.
Staff did not ensure the dishware is properly cleaned.
Staff did not properly address a client's change in medical condition.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 01/30/2025, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility to deliver the findings of the above allegations. LPA Brown explained the purpose of the visit to a staff. Staff contacted Administrator Adegboyega Agbulusi and informed of the visit. House Manager Maureen Sevilla and House Manager Charles Okojie arrived during the visit. LPA Brown explained the purpose of the visit to House Managers Sevilla and Okojie. The investigation consisted of file review, interviews with staffs and residents as well as observation.

The investigation was conducted by LPA Brown. The investigation consisted of file review, interviews with relevant parties and observation. The first allegation indicates staff do not keep the facility free from roaches. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interviews with two (2) of two (2) clients indicated that staffs at the facility are keeping the facility free from roaches. Two (2) of two (2) clients interviewed reported that they did not see roaches at the facility. LPA Brown unable to interview one (1) client. ***Continuation of LIC9099C***
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 56-AS-20241211094442
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: MIMOSA HIGHPOINTE
FACILITY NUMBER: 331880782
VISIT DATE: 01/30/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Interview with four (4) of four (4) staffs indicated that they are keeping the facility free from roaches. Four (4) of four (4) staffs interviewed stated that the facility has contracted exterminators that goes to the facility monthly to spray the inside and outside of the facility. During the facility visit on 12/16/2024, Administrator Agbelusi provided LPA Brown monthly service invoice of the facility's contracted exterminator. Moreover, during the quick tour of the facility, LPA Brown did not observe roaches at the facility.

The second allegation indicates that staff did not ensure the dishware is properly cleaned. Interview with two (2) of two (2) clients indicated that dishware are always properly cleaned at the facility and there's no incident that staffs did not make sure that dishware is properly cleaned. Interview with four (4) of four (4) staffs indicated that they are always making sure daily that dishware is properly cleaned. In addition, four (4) of four (4) staffs interviewed stated that when their exterminator arrived at the facility, they make sure that they are properly cleaning and sanitizing the dishware. Also, interviews with four (4) of four (4) staff revealed that there's no incident that happened at the facility that they did not ensure that dishware's properly cleaned. During the facility visit on 12/16/2024, LPA Brown observed the dishware in the kitchen clean.

The third allegation indicates that staff did not properly address a client's change in medical condition. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interview with C1 indicated that C1 always administer C1's insulin medication and C1 stated that there's no incident that C1 was not able to administer C1's insulin medication. Interview with four (4) of four (4) staffs indicated that there's no incident at the facility that C1 had a change of condition that resulted to C1 unable to administer C1's insulin medication.

Based on interviews, records review and observation, the allegation staff do not keep the facility free from roaches (Allegation #1), staff did not ensure the dishware is properly cleaned (Allegation #2), staff did not properly address a client's change in medical condition (Allegation #3) are UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

An exit interview was conducted, where this report (LIC9099) was discussed and provided to House Manager Maureen Sevilla and House Manager Charles Okojie.


SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 56-AS-20241211094442
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: MIMOSA HIGHPOINTE
FACILITY NUMBER: 331880782
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/31/2025
Section Cited
CCR
80075(b)
1
2
3
4
5
6
7
80075 Health Related Services (b) Clients shall be assisted as needed with self-administration of prescription and non-prescription medications.
This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee stated to train all staff on CCR 80075(b) and submit proof of training log to LPA Brown by the Plan of Correction (POC) due date.
8
9
10
11
12
13
14
Based on observation, interview and records review, the Licensee did not comply with the section cited above by not ensuring that staffs at the facility are assisting Client #1 (C1) with C1's medciation which poses an immediate health, safety and personal rights risk to client 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.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5