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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006352
Report Date: 09/15/2026
Date Signed: 09/15/2026 11:50:40 AM

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
09/10/2026 and conducted by Evaluator Jerome Haley
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20260910160152
FACILITY NAME:HILLS OF HAYWARD, THEFACILITY NUMBER:
306006352
ADMINISTRATOR:NEPOMUCENO, MARICELFACILITY TYPE:
740
ADDRESS:835 S HAYWARD STREETTELEPHONE:
(714) 827-1016
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:6CENSUS: 1DATE:
09/15/2026
UNANNOUNCEDTIME BEGAN:
07:45 AM
MET WITH:Maria Luna
Allen Medina via Telephone		TIME COMPLETED:
11:09 AM
ALLEGATION(S):
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Facility did not provide appropriate supervision
Staff did not provide incontinence care to resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jerome Haley made unannounced visit to begin the investigation into the complaint received September 10, 2026. LPA Haley was greeted by staff and explained the reason for the visit upon entry. The complaint investigation consisted of interviews with facility staff, a resident, and document review.

Regarding the allegation: Facility did not provide appropriate supervision
During the investigation it was discovered the facility is currently dealing with staffing issues. Due to the staffing issues residents have been left alone without the presence of a facility staff person. It is unclear how many times this has happened, however, multiple individuals confirmed there’s a problem with staffing. Additional information was provided during the complaint visit and it was discovered on Sunday, September 13, 2026, there was no facility staff person available for a couple of hours during the

Continued on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2026
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-20260910160152
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: HILLS OF HAYWARD, THE
FACILITY NUMBER: 306006352
VISIT DATE: 09/15/2026
NARRATIVE
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evening from 5:00pm until about 8:30pm. This information was confirmed during an interview with Staff 1 (S1) who confirmed there were no staff member present for a couple hours.

Regarding the allegation: Staff did not provide incontinence care to resident
During the investigation it was discovered on Sunday, September 13, 2026, there was no staff present from 5:00pm until about 8:30pm. Two residents were present and one of the two residents needs incontinent care. Since there was no staff present there was no staff member available to provide incontinent care to Resident 1 (R1). Staff 1 (S1) confirmed there was no staff present and added family members of one of the residents was there until a staff member showed up around 8:30pm.

Based on the evidence gathered during interviews and document review, the preponderance of evidence standard has been met, therefore, the allegations are found to be substantiated. Violation are 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: 09/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20260910160152
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: HILLS OF HAYWARD, THE
FACILITY NUMBER: 306006352
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/16/2026
Section Cited
CCR
87413(a)(1)
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87413 Personnel - Operations
(a) In each facility:
(1) When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks.
This requirement was not met as evidenced by:
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Licensee Allen Medina will conduct a training for his staff and emphasize the improtance not leaving their shift prior to the next staff member showing up. Licensee Medina agrees to read and review the regulation guidelines and send a statement of acknowledgment and understanding. Allan will also provide a written plan/outine that will prevent the lack of staffing from happening again. POC is due by 4:00pm on the POC due date.
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On September 13, 2026, the facility staff member had to leave at their scheduled end time and there was no facility staff person available from 5:00pm until around 8:30pm when the next facility staff person arrived a few hours later.
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Type A
09/16/2026
Section Cited
CCR
87652(b)(2)
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87625 Managed Incontinence
(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following:
(2) Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night.
This requirement was not met as evidenced by:
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Facility Licensee Allen Medina agrees to review the regulation guidelines with all the caregivers and provide a signed statement that the regulation has been reviewed and understood from all staff that have reviewed the regulation. POC is due by 4:00pm on the POC due date.
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On September 13, 2026, there was no facility staff person available from 5:00pm until around 8:30pm to check or change R1 who requires incontinent care and needs to be changed frequently.
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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: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2026
LIC9099 (FAS) - (06/04)
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