306004839-8-20-2026-22-AS-KSGH-DYCTJB-20260928144602

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004839
Report Date: 08/20/2026
Date Signed: 08/20/2026 03:48:34 PM

Unfounded

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 VILLA		FACILITY NUMBER:	306004839
ADMINISTRATOR:	JAE WAN RIM		FACILITY TYPE:	740
ADDRESS:	2441 W. ORANGETHORPE AVE.		TELEPHONE:	(714) 992-5380
CITY:	FULLERTON	STATE: CA	ZIP CODE:	92833
CAPACITY:	197	CENSUS: 175	DATE:	08/20/2026
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Jae Wan Rim		TIME COMPLETED:	03:55 PM

ALLEGATION(S):

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Staff refuse to provide resident's with their medications
Facility does not have sufficient staff
Staff administering medication are unqualified

INVESTIGATION FINDINGS:

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Regarding the allegation: Staff refuse to provide resident's with their medications

During interviews, 11 individuals provided information that contradicts the complaint allegation. All the residents who were interviewed confirmed they receive their medication on time. On resident self administers their own meds and receives assistance from the facility when they need refills. Multiple witnesses confirmed their family member receiving care at from the facility, receives their medication on time and as prescribed. According to Witness 2 (W2), the facility has a nurse on staff, the Administrator is very responsive, and W2 claims their mother’s condition seems to be improving.

Regarding the allegation: Facility does not have sufficient staff

During interviews and LPA’s observations there was no corroborating evidence or information provided or observed. During the tour of the facility, there were plenty of staff everywhere and on both floors.
Continued on LIC9099C

Unfounded

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)

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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

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Staff were observed cleaning rooms, in the medication room, and in the front office. According to the Administrator there are about 17 care staff working on the day shift. 12 – 14 care staff working the pm shift, and 4 care staff working the night shift. All the residents who were interviewed, claims staff are responsive to their calls for assistance. According to a family member of a resident who visits the facility every week, there’s always people hanging around on the floor and you can easily find them.

Regarding the allegation: Staff administering medication are unqualified

During record review, staff training records were provided for all med techs. All med techs have medication training, are CPR certified, and have received in-house medication training. According to the Administrator, med techs are shadowed for a long time before they are allowed to pass medication on their own. Saint Mary Pharmacy assist the facility with in-service medication training's. Certificates were provided.

Based on the information gathered through interviews, document review, and observations the allegations are deemed unfounded, meaning the allegations are false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted, and a copy of this report and was 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)

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