Garden Grove Guest Home Llc

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: - Resident’s representative was not provided with a copy of the admission agreement - Facility staff did not communicate with the authorized representative - Facility staff did not ensure residents’ information was kept confidential

On this date, Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit to conclude and deliver findings for a complaint investigation. LPA Tea was greeted and granted entry by facility staff and explained the purpose of the visit. Assistant Administrator (AA) Paige Rohrer arrived shortly to assist with the inspection. The Department received a complaint on May 18, 2026. During the investigation, LPA Tea conducted interviews with residents, witnesses, and facility staff, and reviewed and collected pertinent records and information. Regarding the allegation that the resident's representative was not provided with a copy of the admission agreement, interviews revealed that the responsible party received a copy of the admission agreement. (Complaint Investigation Report continued on LIC9099-C) Unsubstantiatedthe state’s words, verbatim · CDSS document, Jun 11, 2026 · control 22-AS-20260518141019

Allegation investigated: Staff did not prevent a resident from developing a pressure injury. Staff did not administer medication to a resident in care.

Licensing Program Analyst (LPA) Hanna Gough arrived at the facility to investigate the above mentioned complaint allegation. LPA was greeted and granted entry by staff. LPA met with Assistant Administrator (AA) Paige Rohrer and discussed the purpose of the visit. The investigation into the allegation of staff did not prevent a resident from developing a pressure injury revealed the following: Resident #1(R1) was admitted to the facility on March 20, 2022. LPA observed a physicians report for R1 dated March 20, 2022, stating that R1 had no history of a skin condition/breakdown and that they were able to communicate their needs. R1 was marked as ambulatory on the physicians report. LPA did not observe an updated physicians report for R1. LPA observed a functional capability assessment for R1 dated April 2, 2023, stating that R1 needed full assist with bathing, dressing, toileting, transferring, eating, grooming and repositioning. LPA observed that R1 was noted to be able to make their nethe state’s words, verbatim · CDSS document, Jan 13, 2026 · control 22-AS-20230905130429

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Resident sustained unexplained bruising while in care Staff did not seek timely medical attention for a resident

Licensing Program Analyst (LPA) Hanna Gough arrived at the facility to investigate the above mentioned complaint allegations. LPA was greeted and granted entry by staff. LPA met with Assistant Administrator (AA) Paige Rohrer and discussed the purpose of the visit. The investigation into the facility allegations of resident sustained unexplained bruising while in care and staff did not seek timely medical attention for a resident revealed the following: Resident #1 (R1) was admitted to the facility October 18, 2023. LPA observed a physicians report dated October 18, 2023, stating that R1 had a diagnosis of dementia and had motor impairment with a note of using a roller walker. R1 did not have a history of a skin condition/breakdown. R1 was noted as non ambulatory due to their physical condition. LPA observed a needs and services plan dated October 18, 2023, stating that R1 was returning from a skilled nursing facility due to a fall. The needs and services plan noted that R1 had no physithe state’s words, verbatim · CDSS document, Dec 12, 2025 · control 22-AS-20240430125543

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff did not ensure residents thermostat in room was working properly. Staff did not ensure residents room does not smell like urine. Staff did not ensure residents bathroom and floors are cleaned timely.

Licensing Program Analyst (LPA) Jessica Cho made an unannounced subsequent visit for the purpose of continuing the investigation into the above allegations. LPA met with Assistant Administrator(AA)/Wellness Director (WD) Paige Rohrer and explained the reason for the visit. On April 13, 2023, the Department received the complaint which the investigation was initiated by LPA Jenifer Tirre on April 20, 2023. During the course of the investigation, LPA Tirre and/or Cho toured the faciltiy, conducted interviews with two staff and four residents, and obtained the following documentation: Resident/Staff Rosters, Housekeeping Schedule, Face Sheets, and Physician's Reports. The investigation is as follows: Regarding the allegation, Staff did not ensure resident's thermostat in room was working properly, it is alleged that the thermostat in the unit was broken for three months. LPA observed no thermostats in the the four resident units inspected also corroborated by two out of two staff. Unfoundthe state’s words, verbatim · CDSS document, Nov 3, 2025 · control 22-AS-20230413144738

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff neglect resulted in a resident sustaining multiple fractures while in care.

On 05/19/25, Donna Gurriere, Licensing Program Analyst (LPA) contacted the licensee/administrator via telephone to deliver final findings regarding a complaint that was received 12/06/2023. LPA Gurriere spoke with Connor Kelley, Administrator and explained the purpose of the call. Staff neglect resulted in a resident sustaining multiple fractures while in care. During the interview process, the administrator, assistant administrator, four staff persons and two doctors were interviewed. In addition, documents were reviewed and obtained to include the Physicians Report, Incident Report, Death Certificate, and Medical Records of the resident (Resident 1). continued Unsubstantiatedthe state’s words, verbatim · CDSS document, May 20, 2025 · control 22-AS-20231206162230

Allegation investigated: Unqualified facility staff are administering injections to residents

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on the investigation of the four allegations listed above. LPA was greeted and granted entry by facility wellness director Paige Rohrer after explaining the purpose of the visit. An initial investigation visit took place on September 4, 2024. During the visit, LPA requested and obtained the facility census, staff roster, resident records for six admitted individuals including physician orders and medication administration records as well as reviewed the medication carts. Interviews with the facility's wellness director and administrator conducted. During the present visit, LPA requested the facility census and staff roster. Resident and staff interviews were conducted along with a tour of the two hallways of the facility. Additional record requested and reviewed. CONTINUED ON FORM LIC809-C Substantiatedthe state’s words, verbatim · CDSS document, Nov 18, 2024 · control 22-AS-20240827122914

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Resident sustained an unexplained fracture while in care of staff.

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced complaint visit to deliver findings on the above allegation received on February 22, 2024. LPA was greeted and granted entry into the facility and met with Medication Technician (MT) Daniel Lazareno. LPA explained the reason for the visit. This Department has investigated the complaint alleging that resident sustained an unexplained fracture while in care of staff. Resident 1 (R1) was admitted to the facility in October 20, 2022. Documents reviewed included the Physician Report (LIC602) dated March 01, 2023, for R1. Per Physician report R1’s diagnosis are osteoporosis and dementia. On November 27, 2023, R1 was admitted to Fountain Valley Hospital. The Hospital admitting diagnosis were abdominal pain, hyperkalemia, and dehydration. R1’s abdominal CT scan and chest x-ray demonstrated bilateral rib fractures including right lateral 7th and 8th ribs and left lateral 4th rib fracture. CONTINUED ON LIC9099-C... Unsuthe state’s words, verbatim · CDSS document, Jul 5, 2024 · control 22-AS-20240222150108

Allegation investigated: Resident sustained unwitnessed fall at the facility.

Licensing Program Analyst (LPA) Ruth Martinez visited the facility to deliver findings for the investigation into the above identified complaint allegations. LPA met with Ruben Ramirez, Administrator and explained the nature of the visit. Based on the information obtained during this investigation the department has concluded the investigation into the above mentioned allegation. Findings are based upon this investigation which included interviews conducted, physical plant tour, and copy of pertinent documents obtained. It is alleged resident sustained unwitnessed fall at the facility. Review of records obtained resident (R1) is able to ambulate in the facility with assistance from a front wheel walker. Appraisal/needs and services plan indicate that R1 uses a front wheel walker to ambulate, plan is to use cane, objective is to remind resident to keep ambulation Continued on LIC9099-C Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 26, 2024 · control 22-AS-20211228104511

Allegation investigated: insufficient staffing to meet resident's needs Staff are not answering residents call lights timely

Licensing Program Analyst (LPA) Ruth Martinez visited the facility to deliver findings for the investigation into the above identified complaint allegations. LPA met with Ruben Ramirez, Administrator and explained the nature of the visit. Based on the information obtained during this investigation the department has concluded the investigation into the above mentioned allegations. Findings are based upon this investigation which included interviews conducted, tour of phydical plant and copies of pertinent documents obtained. It is alleged that the facility has insufficient staffing to meet residents’ needs. Records review revealed that at the time of visit facility census was 32 and facility staff schedule showed the facility to have 12 caregivers on the schedule. The monthly caregiver staffing schedule reflected that there were five shifts per day and there was two to three caregivers scheduled per shift. Interview with Administrator indicated that all shifts had caregivers and Continthe state’s words, verbatim · CDSS document, Feb 26, 2024 · control 22-AS-20220804082401

Allegation investigated: Staff stole resident's money.

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on the investigation of the allegation listed above. LPA was greeted and granted entry by facility staff after explaining the reason for the visit. An initial complaint investigation visit was conducted on November 15, 2023. LPA requested and obtained records for four residents in care in addition to a list of the current facility employees. LPA accompanied by administrator conducted a tour of the facility's physical plant. Facility administrator also provided LPA with the staff schedule for the month of November including all current facility employees. An interview with administrator was conducted. CONTINUED ON FORM LIC9099-C Unfoundedthe state’s words, verbatim · CDSS document, Nov 22, 2023 · control 22-AS-20231113105418