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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004839
Report Date: 08/20/2026
Date Signed: 08/20/2026 03:47:23 PM

Substantiated


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
08/13/2026 and conducted by Evaluator Jerome Haley
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20260813133954
FACILITY NAME:FULLERTON VILLAFACILITY NUMBER:
306004839
ADMINISTRATOR:JAE WAN RIMFACILITY TYPE:
740
ADDRESS:2441 W. ORANGETHORPE AVE.TELEPHONE:
(714) 992-5380
CITY:FULLERTONSTATE: CAZIP CODE:
92833
CAPACITY:197CENSUS: 175DATE:
08/20/2026
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Jae Wan RimTIME COMPLETED:
11:59 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not provide medications as prescribed
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit regarding the complaint allegation above. LPA was greeted by staff and explained the reason for the visit upon entry.

During the visit, LPA Haley was led on a tour of the facility by staff. After the tour, LPA Haley reviewed medications for 16 residents, conducted interviews with residents, staff, and contacted resident family members.

Regarding the allegation: Staff do not provide medications as prescribed

During medication review it was discovered, R1’s medication administration record (MAR) revealed a Tab-A-Vite Multivit with Iron was not available for review with the rest of the residents centrally stored medications.
Continued on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2026
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 3
Control Number 22-AS-20260813133954
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: FULLERTON VILLA
FACILITY NUMBER: 306004839
VISIT DATE: 08/20/2026
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
The medication is listed on the MAR and it’s unclear if the medication was listed by the pharmacy by mistake, or if the medication is included in the Multivitamin with Minerals Tab that is being administered as prescribed and listed on the MAR and the Tab-A-Vite medication is a duplicate. During interviews, the Administrator agreed that even if the medication is a duplicate, it should have been caught by staff and marked as duplicate on the MAR.

Based on the evidence gathered during medication review and interview confirmation, the preponderance of evidence standard has been met, therefore, the allegation is found to be substantiated. A violation is being cited per California Code of Regulations Title 22.

An exit interview was conducted, and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20260813133954
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: FULLERTON VILLA
FACILITY NUMBER: 306004839
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/21/2026
Section Cited
CCR
87465(h)(2)
1
2
3
4
5
6
7
Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored:
(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
This requirement was not met as evidence by:
1
2
3
4
5
6
7
Administrator Jae will follow up with the pharmacy to find out exactly what happened with the medication and if it was a duplicate or not and share his findings with LPA Haley. Administrator Jae will provide an explanation on how this oversight will be prevented in the future.
8
9
10
11
12
13
14
During medication review for R1, Tab-A-Vite Multivit with Iron was not available. It was initialed on the medication administration record; however, the medication was not available with the other centrally stored medications.
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.
SUPERVISOR'S NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3