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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005782
Report Date: 08/13/2026
Date Signed: 08/13/2026 03:06:30 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
08/12/2026 and conducted by Evaluator Jessica Cho
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20260812162938
FACILITY NAME:RESPIT MANOR MISSION VIEJOFACILITY NUMBER:
306005782
ADMINISTRATOR:MENDEZ, MARKFACILITY TYPE:
740
ADDRESS:23412 VIA GUADIXTELEPHONE:
(949) 331-7578
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 3DATE:
08/13/2026
UNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Mark Mendez- AdministratorTIME COMPLETED:
03:06 PM
ALLEGATION(S):
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Facility did not issue responsible party a refund.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jessica Cho made an unannounced visit for the purpose of initiating the complaint investigation into the above allegation. LPA was greeted and granted entry by Caregiver John Panganiban and explained the reason for the visit. Administrator (Admin) Mark Mendez was informed of the visit by telephone and arrived at 2pm. During the course of the investigation, LPA interivewed two staff and obtained the following pertinent documentation: Resident Roster, Personnel Report Summary, Face Sheet, Physician's Report, Admission Agreement, hospice records, bank statement, and text message receipts.

The investigation revealed the following: Regarding the allegation, facility did not issue the responsible party a refund, it is alleged the representative of Resident #1 (R1) was not issued a refund after Resident #1 (R1) passed away. R1 began hospice care on February 19, 2026 and passed away on May 2, 2026 per face sheet. LPA verified faciity did not comply with the reporting requirements as the Department did not receive a death report for R1.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2026
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-20260812162938
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: RESPIT MANOR MISSION VIEJO
FACILITY NUMBER: 306005782
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/27/2026
Section Cited
CCR
87507(g)(5)(A)
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87507 Admission Agreements (g) Admission agreements shall specify the following: (5) Refund conditions. (A) Facility policy concerning refunds, including the conditions under which a refund for advanced monthly fees will be returned in the event of a resident’s death, pursuant to Health and Safety Code section 1569.652.

This requirement was not met as evidenced by:
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Administrator stated proof of $5000.00 refund certified mailed to R1's representative and proof the issued amount has been withdrawn by POC due date to LPA via email by POC due date.
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Based on interview and record review,
facility issued a partial $500.00 refund after R1 passed on 5/2/26 and still has an outstanding balance owed of $5k which poses a potential Personal Rights risk to persons in care.
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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: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20260812162938
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: RESPIT MANOR MISSION VIEJO
FACILITY NUMBER: 306005782
VISIT DATE: 08/13/2026
NARRATIVE
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Per the admission agreement, R1's rate is $5,500.00. Admin Mendez confirmed R1's representative was issued a $500.00 refund which R1 confirmed via text on July 8, 2026 at 12:32pm. R1 confirmed still having an outstanding balance of $5000.00. Admin indicated R1's representative will be reimbursed the full amount although resident resided at the facility for two days in May 2026.

Therefore, based on the interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegation: Facility did not issue responsible party a refund is deemed SUBSTANTIATED. A deficiency is being cited on the attached LIC9099D.

An exit interview was conducted with Administrator Mark Mendez, and a copy of this report including the LIC9099C, LIC811, and the appeal rights were provided at the end of the visit.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3