Abundant Grace Care Villa

Allegation investigated: - Staff isolated resident - Staff handled resident roughly, causing injury - Staff yelled at resident - Staff did not provide adequate food service to resident, resulting in weight loss

On this day, 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 Licensee (LE) Theresa Dompreh-Mensah and explained the purpose of the visit. The Department received the complaint on April 29, 2026. LPA Tea conducted the initial 10-day visit on May 7, 2026. During the investigation, LPA Tea interviewed residents and facility staff and reviewed and collected relevant records and information. It was alleged that staff isolated the resident. Resident 1 (R1) denied being isolated but reported that staff sometimes ignored them and did not provide the amount of attention they wanted. R1 reported spending time in their room and wanting staff to spend more time with them. (Complaint Investigation Report continued on LIC9099-C) Unsubstantiated R1's Responsible Party denied that R1 was isolated and reported that R1 preferred a private room, did not want to be bothered by others, and frequently wanted one-to-one attention. The Responsible Party also reported that R1 communicated with family by telephone and received visitors. Four out of four staff interviewed denied isolating R1. Staff reported that R1 preferred privacy, frequently remained in their room or bed, received one-to-one care, and had visitors. Records reviewed documented R1's contact with family and others while residing at the facility. Progress notes documented visits from R1's family and friend, telephone contact with family, and occasions when R1 spent time outside of their room. R1's Appraisal/Needs and Services Plan also identified socialization needs and directed staff to encourage social interaction and participation in activities. It was alleged that staff handled resident roughly, causing injury. R1 reported that staff were rough with them during personal care, including changing and repositioning. R1 stated that staff pulled on them and caused them pain. R1's Responsible Party reported that R1 had complained to family that staff were rough with them but stated that they did not personally witness staff mistreat R1. Four out of four staff interviewed denied handling R1 roughly or causing injury. Staff reported that R1 required assistance with personal care, transfers, and repositioning. Three out of three residents interviewed denied witnessing staff handle R1 roughly. All three residents also reported that staff did not handle them roughly and described caregivers as gentle. Medical records showed that R1 had significant physical limitations before admission to the facility, including left-sided weakness/paralysis related to a previous cerebrovascular accident and tenderness to the left posterior elbow. R1's Appraisal/Needs and Services Plan documented that R1 required assistance with transfers, repositioning, feeding, grooming, toileting, and other activities of daily living. Records also documented complaints of shoulder pain during R1's placement and that R1 was sent for medical evaluation. During one incident involving personal care and repositioning, R1 became upset and reported that staff had injured them. However, the records reviewed did not establish that R1 sustained an injury as a result of staff handling them roughly. (Complaint Investigation Report continued on LIC9099-C) It was alleged that staff yelled at resident. R1 reported that staff yelled at them while they resided at the facility, including during personal care. R1's Responsible Party reported that R1 frequently complained about caregivers and how staff treated them. However, the Responsible Party stated that they did not personally witness staff yell at or mistreat R1. Four out of four staff interviewed denied yelling at R1 and reported that staff attempted to meet R1's needs and requests. Staff reported that R1 sometimes became upset during personal care. One staff member reported being hard of hearing and stated that R1 and R1's family were aware of this. Two out of three residents interviewed reported that they had not witnessed staff yell at R1 or other residents. One resident reported hearing yelling but could not determine whether the yelling came from a staff member or a resident. Facility records documented occasions when R1 became upset during personal care and repositioning. During one incident, R1 became upset while staff were providing care and made statements that they needed help and that staff wanted to harm them. The records did not establish that staff yelled at R1. It was alleged that staff did not provide adequate food service to resident, resulting in weight loss. R1 reported concerns regarding food service at the facility. R1 stated that they were a slow eater and that staff sometimes rushed them or removed their food before they finished eating. R1 also reported that breakfast portions were sometimes too small and that family occasionally brought them outside food. However, R1 denied losing weight while residing at the facility. Four out of four staff interviewed denied withholding food or failing to provide adequate food to R1. Staff reported that meals were provided and that R1 received assistance with their nutritional needs. Staff also reported that R1's family sometimes brought outside food for R1, including fast food and snack foods that staff considered less nutritious. Two out of three residents interviewed reported being satisfied with the facility's food service. One resident reported that the food was good but felt the portions were sometimes not enough. During the visit, LPA Tea observed a sufficient supply of perishable and nonperishable food at the facility. Records reviewed documented R1's food and fluid intake during their placement, including multiple entries (Complaint Investigation Report continued on LIC9099-C) showing that R1 ate meals and drank fluids. Records also documented occasions when R1 ate outside of their room. R1's Appraisal/Needs and Services Plan identified the need for assistance with feeding and directed staff to monitor R1's nutritional intake. Although R1 reported concerns regarding food portions, being rushed, and food being removed before they finished eating, the investigation did not establish that R1 experienced weight loss due to inadequate food service. Based on interviews conducted and records reviewed, the allegations above are determined to be UNSUBSTANTIATED, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred. No deficiencies are being cited regarding the above allegations at this time. An exit interview was conducted with Licensee Theresa Dompreh-Mensah, and a copy of this report was provided to the facility. but has a separate address and license. The facility is licensed to serve four non-ambulatory residents, all of whom may be bedridden, and has a hospice waiver for four residents. R1's Responsible Party reported that R1 was later moved to the main facility during their placement but did not provide information showing that R1 had been housed in an unlicensed building. Licensee James Mensah denied that R1 was housed in an unlicensed building and reported that R1 initially resided at a licensed facility. Four out of four staff interviewed also reported that the building where R1 initially resided was licensed. During the investigation, LPA Tea observed a valid facility license at Abundant Grace Care Villa 2. LPA Tea also reviewed Department licensing records and verified that the facility was licensed. Therefore, the investigation established that R1 was not housed in an unlicensed building. Based on interviews conducted, observations, and Department records reviewed, the allegation that staff housed R1 in an unlicensed building is determined to be UNFOUNDED, meaning that the allegation was false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted with Licensee Theresa Dompreh-Mensah, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 17, 2026 · control 22-AS-20260429094244

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Hanna Gough made an unannounced visit to the facility to conducted the required annual inspection. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Theresa Dompreh-Mensah and discussed the purpose of the visit. The facility currently has 5 residents in care. The facility is a one story home with three resident bedrooms, two resident bathrooms, one caregiver room, one caregiver bathroom, living room, kitchen, dining room and attached two car garage. The facility appears clean, safe and sanitary. All resident bedrooms have the required components and furnishings. LPA observed a fresh supply of linens in the closet located in the hall by the resident rooms. LPA observed the bathrooms to have toilet paper, paper towels and texture shower flooring. LPA observed the caregiver room to be clean and free of medications and toxins. LPA observed the kitchen to be clean and free of vermin. LPA observed a two day perishable and seven day non perishable supply on hand. LPA advised AD that they are at the minimum supply to meet regulatory requirements and advised that more groceries need to be purchased as to not go below what is required to maintain compliance. The medications are locked and stored in a kitchen cabinet making them inaccessible to residents in care. The knives and sharps are locked in a kitchen drawer by the sink making them inaccessible to residents in care. Toxins and chemicals are locked under the kitchen sink making them inaccessible to residents in care. LPA observed a fire extinguisher charged and with a service date of December 1, 2025, mounted to the wall next to the See Something Say Something poster in the living room by the entrance of the kitchen. LPA observed the garage to be locked and made inaccessible to residents in care. The emergency food and water supply was observed in the garage cabinets. LPA observed a shaded seating area for resident use and no debris or obstructions were observed on the outside of the facility. Continue on LIC809C AD tested the carbon monoxide and smoke detectors and they were found to be operational. LPA reviewed staff records and no discrepancies were observed. LPA reviewed resident records and observed 3 of 5 residents do not have bed rail orders for the half bed rails that were observed during the tour of the facility. LPA reviewed the emergency disaster plan has not been reviewed/updated and does not include newer staff. LPA reviewed the last disaster drill was conducted on February 1, 2026. LPA reviewed resident medications and no discrepancies were observed. All staff present are background cleared and associated to the facility. Based on today’s inspection a deficiency along with technical violation and advisory are being noted per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report along with LIC809D, LIC858, technical violation, advisory, and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Mar 3, 2026

The state marks this report as 6 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) William Vanegas made and unannounced inspection for the purposes of completing an annual inspection. Upon arrival LPA Vanegas was greeted and granted entry to the facility and explained the purpose of the inspection. LPA Vanegas set up equipment and began a tour of the facility and observed the following. Currently there are no residents in care. This is a one storied home with four bedrooms, one of which is a staff room, and three of which are resident rooms. There are two bathrooms one private bathroom and one shared bathroom. LPA Vanegas observed kitchen area to be clean and free of mildew and debris, there is a dishwasher, refrigerator, microwave, and gas stove that are in good repair, and tested operational. Resident bathrooms were observed to have functional toilets, and sinks. Along with all required furnishings, water tested between 135.3 and 136.2 Licensee was advised to lower water temperature prior to residents moving in.All bed rooms are ready for resident use, and have the required furnishings such as a lamp, chair, bed, and clean linens in good repair; meaning no strains or tears. Rooms are large enough to walk about freely, and no obstructions are blocking entry ways. LPA Vanegas observed an additional back house that is unoccupied, and is in the process of becoming licensed as well, this is a back house that has a different address, and is in good repair and vacant.LPA Vanegas observed outside of the facility to be clean and spacious, no obstructions are blocking emergency exit routes. Backyard is big enough to participate in outdoor activities upon resident request. LPA Vanegas observed all proper postings to be displayed along entry way of the facility. LPA Vanegas observed first aid kit to have all required items such as adhesive tape, scissors, tweezers, a thermometer, and a first aid manual. LPA Vanegas observed fire extinguishers to be up to date, and fully charged. LPA Vanegas observed smoke and carbon monoxide detectors to be in good repair and operational. Based on observations made during todays inspection no deficiencies will be cited per title 22 chapter 8 division 6 of the California Code of Regulations. An exit interview was completed with Licensee Theresa Dompreh and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Mar 7, 2025

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Dwayne Mason Jr. made an announced inspection to the facility for purpose of conducting a pre-licensing inspection. LPA arrived and was greeted and granted entry by Administrator Theresa Dompreh-Mensah and Vice-President, James Mensah. An application to operate a Residential Care Facility for the Elderly (RCFE) for (6) capacity, (0) ambulatory, (5) non-ambulatory, and (1) bedridden residents was received by Community Care Licensing (CCL) on 9/13/2023. The facility is a one-story home with three shared resident bedrooms, three bathrooms, living room, dining room, kitchen, office/staff room, attached two car garage and backyard. LPA did not observe any obstructions blocking the exit gate or obstacles or hazards in the backyard. Client Bedrooms have all the necessary requirements including bed, chair, storage for clothing and ample lighting. LPA observed all windows were screened. All bathrooms have working plumbing and designated hand washing posters. Hot water initially measured above 120 degrees Fahrenheit. AD stated they had adjusted the hot water heater prior to the inspection. LPA observed the hot water to be within the correct range during the inspection. LPA issued a technical assistance advising the AD to maintain a daily water log to ensure proper temperatures are maintained. LPA observed the fire extinguisher to be fully charged as indicated by the arrow pointing in the green zone. LPA observed a service tag indicating the fire extinguisher was serviced on 9/13/2023. Medications, First-Aid Kit, Resident & Staff Files will be locked in cabinets in the kitchen. The fire clearance was approved by a fire inspector of Orange County Fire Authority on 12/1/2023. A supply of extra linens is stored in a closet in the hallway. LPA observed chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents and are stored and locked in the kitchen, bathrooms and garage. Emergency Phone Numbers, and Exit Plan are all posted and available for review. LPA observe an 8.5" x 11" PUB 475 posted. AD placed an order for a 20" x 26" print of the PUB475 during the inspection. Smoke and Carbon Monoxide detectors are stationed throughout the home and are wired together. Both types of detectors were tested and noted as operational. Operational appliances include a gas stove, oven, two refrigerators, dishwasher, microwave, washing machine and dryer. The facility has a cabinet of activity supplies including but not limited to arts and crafts, board games and more. LPA reviewed and provided Administrator with the Component III presentation to offer information and resources regarding maintaining facility compliance. The designated AD was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. Exit interview was conducted and a copy of this report was provided to designated AD.the state’s words, verbatim · CDSS document, Mar 21, 2024

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Office

Facility Type: RCFE Application Type: Initial Capacity: 6 COMP II Participant: Theresa Dompreh-Mensah, CEO/Administrator Interview Method: Telephone interview On 3/11/24, applicant/administrator participated in COMP II. Identification of the applicant/administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant/administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Mar 11, 2024