Morningstar Senior Living of Mission Viejo

Allegation investigated: Staff are not reporting incidents to resident’s representative Staff did not obtain medical care for resident

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required 10-day visit to begin the investigation into the allegations listed above. LPA mew with Executive Director Danny Vera and Wellness Director Melinda Mandviwala and explained the reason for the visit. The investigation into the allegation, staff are not reporting incidents to resident’s representative, revealed the following. It was reported that Resident 1 (R1) has fallen numerous times and the facility has not notified the responsible party. A review of incidents reports submitted to the Agency (Community Care Licensing) shows that 2 incident reports for R1 have been submitted. One for a fall on June 7, 2026, and one on June 23, 2026, for blood in R1’s urine. In both cases 911 was called and R1 was transported to the hospital and treated. R1’s responsible party verified that they were notified of both incidents. There are no other reports of any incidents involving R1. The Wellness Director reported that those are the only 2 incidents involving R1. Unfounded R1’s responsible party reported that the facility regularly communicated with them concerning R1 and they were not aware of any other incidents involving R1. R1 has been moved out of the facility on June 29, 2026. 3 out of 3 staff interviewed reported that they were unaware of any other incidents involving R1. Based on the evidence gathered the allegation is deemed unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. The investigation into the allegation, staff did not obtain medical care for resident, revealed the following. It was reported that on June 24, 2026, R1 had blood in their urine, and the facility waited hours to call 911. A review of incident reports shows that on June 23, 2026, R1 was noted to have blood in their urine and 911 was called. Staff 1 reported that blood was not noticed in R1’s catheter until around 9:00pm at night and 911 was called immediately. R1’s responsible party was present during the incident and reported that because of this it was decided that 911 should be called. R1’s responsible party reported they don’t know when the blood was first noticed. Staff 1 and the Wellness Director both reported that R1 returned the same day with no new orders. R1’s responsible party reported that R1 was treated and released back to the facility with no new orders. No other witnesses were reported to have been present during the incident. No incident took place on June 24, 2026, involving R1. There is no evidence to support the allegation. The evidence gathered refutes the allegation. Therefore, based on the evidence gathered the allegation is deemed unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of the report provided. R1’s responsible party reported they moved R1 out of the facility because they wanted R1 to have more individualized care. R1’s responsible party reported that they didn’t feel comfortable with R1 at the facility and felt it was better to leave the facility. The incidents involving R1 cannot be attributed to staff not meeting R1’s needs. There were only 2 incidents and after each incident the facility called 911 and made sure R1 received the required medical assistance. The Wellness Director and 3 out of 3 staff reported that R1 received proper care and supervision and any issues were reported to the responsible party and R1’s physician. Based on the evidence gathered, the allegation is deemed unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 8, 2026 · control 22-AS-20260702131813

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA met with Executive Director Danny Vera and explained the reason for the visit. Danny Vera's Administrator's Certificate expires on November 14, 2027. Facility is licensed for 76 ambulatory and 122 non-ambulatory of which 122 may be bedridden. Facility has an approved hospice waiver for 20 and there are 133 residents present today with 10 on hospice. LPA and the Executive Director toured the facility. The facility has 4 levels, the ground level (1st Floor) has the main entrance and lobby. There is basement level with an underground parking. The basement level has elevator access and has a game room for residents. LPA observed the facility emergency food and water supply stored in the basement level. The facility has a 3 day supply of food and water for emergencies. Residents reside on levels 1, 2 and 3. LPA observed all stairways have emergency evacuation chairs. All fire extinguishers in the facility were found to be fully charged. There is an outdoor patio on the First floor with shaded seating for the residents to sit outside. There is a pool in the outdoor patio. The pool is surrounded by a 5 foot tall fence with a gate a each end. Both gates are secured. LPA observed residents listening to a speaker in the theater room. LPA observed residents playing cards in the main sitting area in the lobby. The resident library on the first floor has a computer with internet access for dedicated resident use. LPA observed the See Something Say Something poster (PUB 475) in the main entrance of the facility. LPA and the Executive Director toured the kitchen and dining room. LPA observed the kitchen and dining room are clean and organized. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. LPA observed the walk-in refrigerator in the kitchen was at 38.0 degrees Fahrenheit and the walk- in freezer was at 0.1 degrees Fahrenheit. LPA reviewed the temperature logs for the freezer and refrigerator and the logs are up to date. LPA inspected the medication room on the second floor. LPA observed all medications were secured in the medication room. LPA inspected the first aid kit in the medication room. The first aid kit has all the required elements. Memory care is on the first floor and has delayed egress exits. LPA tested the delayed egress exits and they are all operational. The memory care area has a patio with shaded seating areas. No bodies of water in the memory care patio. LPA toured 13 resident rooms with the Executive Director. Rooms inspected were on the first, second and third floors. Hot water measured 113.0 to 115.5 degrees Fahrenheit. LPA observed all rooms were clean and had the required furnishings and bed linens. LPA tested the smoke/carbon monoxide detectors in each room inspected. All detectors tested are operational. The last emergency drill (fire) was conducted on May 16, 2026. LPA reviewed 13 resident files, no discrepancies observed. LPA reviewed 3 staff files. All staff observed at the facility are background cleared and associated to the facility. LPA observed Staff 1 had over 20 hours of training but did not have 4 hours of training in postural supports, restricted health conditions and hospice care, Staff 1 only had 3 hours of training in those areas. No other discrepancies observed. Deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with the Executive Director and a copy of the report along with appeal rights was provided.the state’s words, verbatim · CDSS document, Jun 10, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to follow up on an incident report submitted to the department on 05/02/2026. LPA was greeted and granted entry into the facility and explained the reason for the visit. Incident report dated 04/28/2026 indicated Resident 1 (R1) was found by staff on the restroom floor. The resident reported pain and was transferred to Mission Hospital where the resident was diagnosed with a right hip fracture. Resident was transferred to a skilled nursing facility post-op and has not returned to the facility to date. Per physician report dated 08/20/2025, R1 is diagnosed with Dementia. During the visit, LPA reviewed and obtained pertinent documentation such as facility notes. Based on observations made during today's visit, NO deficiencies are being cited. Exit interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 22, 2026

Allegation investigated: Unqualified staff administering medication to residents in care

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the visit, LPA toured the facility and interviewed staff as well as reviewed and obtained pertinent documentation such as training records. Regarding the allegation that unqualified staff are administering medication to residents in care, the investigation revealed the following: LPA reviewed Medication Technician training records. Five out of five records reviewed show staff have received training. All staff interviewed stated receiving required training. Based on record review and interviews conducted, the allegation is deemed UNFOUNDED, meaning the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report was provided to facility representative. Unfoundedthe state’s words, verbatim · CDSS document, Oct 27, 2025 · control 22-AS-20250919130858

Type of visit: Collateral

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced collateral visit in conjunction with complaint investigation #22-AS-20250122140204 at another licensed facility. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the visit, LPA interviewed Resident 1 (R1) as well as obtained contact information for staff needed for investigative interviews. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jul 30, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit to Morningstar Senior Living of Mission Viejo. The purpose of today’s visit was to conduct the Annual Required inspection. LPA was allowed entry into the facility and explained the reason for the visit. Facility is licensed for 76 ambulatory and 122 non-ambulatory of which 122 may be bedridden. Facility has an approved hospice waiver for 20 and there are 125 residents present today with 5 on hospice. George Gonzalez has an administrator certificate expiring on 05/10/2027. LPA Lyman along with Administrator Gonzalez toured the facility at 9:18 AM. LPA toured the physical plant, checked food service, facility records and the first aid kit. Facility consists of assisted living and memory care. Facility appears to be clean, safe, and sanitary. Throughout the property, LPA observed multiple outside areas/ patios, two dining rooms as well as a bistro, fitness area, theater, activity areas and a secured swimming pool. There is approved delay egress in the memory care unit. Resident apartments had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident restrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 114.8 and 122.1 degrees F in facility restrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had required elements including thermometer, tweezers and scissors as well as a first aid manual. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Facility is keeping a log of freezer/ refrigerator temperatures and were within range. Smoke detectors and fire inspections are conducted by an outside company, Academy Fire, with the last inspection date of 05/01/2025. Fire extinguishers are fully charged. LPA observed evacuation chairs at stairwells. CONTINUED ON LIC 809C DATED 07/02/2025 LPA observed ample emergency food and water as well as ample emergency supplies. LPA reviewed the emergency disaster plan and infection control plan during the visit. Plans are thorough and complete. Facility conducts quarterly emergency drills with the last drill conducted on 06/05/2025. Facility provides activities in the form of games, exercise, and outings in the community. LPA observed residents participating in activities during the visit and verbalized satisfaction with facility services. LPA observed no health or safety concerns during the visit. LPA reviewed select resident and staff files. Resident files contained required documents including current physician reports and resident appraisals. Staff files reviewed contained required documentation such as health screen/TB, required annual training and first aid/ CPR. LPA reviewed medication administration and storage. Medications are stored in a locked medication cart. Medications are being administered per physician order. Based on observations made during today's visit, NO deficiencies are being cited. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jul 2, 2025

Type of visit: Collateral

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced collateral visit to conduct an interview with witness from complaint #22-AS-20250122140204 at a different licensed facility. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the visit, LPA interviewed Resident 1 (R1). Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jun 6, 2025

Allegation investigated: Licensee did not ensure facility was free from odor

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the facility and interviewed staff and residents as well as reviewed and obtained pertinent documentation such as billing invoices. Regarding the allegation that Licensee did not ensure facility was free from odor, the investigation revealed the following: Facility Administrator indicated an ongoing issue with an odor emanating from the air conditioning vent in the theater. Dykier Air Conditioning was out on 03/03/2025 to investigate the odor and facility is now working with Pacific Coast Refrigeration and Air Conditioning to rectify the situation. The company was out on 03/16/2025, 04/12/2025 and 04/21/2025 to work on the issue and facility provided documentation of visits. LPA noticed a faint odor in the theater during the visit. There is no odor present in any other areas inside the facility. Three out of three residents interviewed stated being unaware of any odors in the facility. CONTINUED ON LIC 9099C DATED 04/30/2025. Unsubstantiated Based on interviews conducted and record review, LPA is unable to corroborate the allegation. Therefore, the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 30, 2025 · control 22-AS-20250422153341

Type of visit: Collateral

Licensing Program Analysts (LPAs) Kimberly Lyman and Fred Arias conducted an unannounced collateral visit regarding a complaint filed at another licensed facility. LPAs were greeted and granted entry into the facility and explained the reason for the visit. During the visit, LPAs toured the facility and interviewed Resident 1 (R1) as well as reviewed and obtained pertinent documentation such as physician report and pre-appraisal. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jan 30, 2025

Type of visit: Collateral

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct a collateral visit in conjunction with complaint # 22-AS-20240710083946 filed against another facility. LPA met with Executive Director (ED) George Gonzalez and explained the reason for the visit. Resident 1 (R1) who could have knowledge regarding the complaint is residing at Morningstar Senior Living. At the time of the LPA's visit R1 was not at the facility. LPA interviewed the ED. LPA requested documents such as physician reports and service plans. During the visit LPA observed the See Something, Say Something sign (PUB 475) is posted in the main entryway of the facility. An exit interview was conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 15, 2024