306003448-6-2-2026-22-AS-AORZ-DV4Q3B-20260616114826

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306003448
Report Date: 06/02/2026
Date Signed: 06/02/2026 10:30:26 AM

Unsubstantiated

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
03/06/2026 and conducted by Evaluator Samer Haddadin

COMPLAINT CONTROL NUMBER: 22-AS-20260306135751

FACILITY NAME:	FULLERTON ROSEWOOD ASSISTED LIVING		FACILITY NUMBER:	306003448
ADMINISTRATOR:	JANE KIM		FACILITY TYPE:	740
ADDRESS:	411 E. COMMONWEALTH AVENUE		TELEPHONE:	(714) 441-0644
CITY:	FULLERTON	STATE: CA	ZIP CODE:	92832
CAPACITY:	99	CENSUS: 51	DATE:	06/02/2026
		UNANNOUNCED	TIME BEGAN:	08:21 AM
MET WITH:	Office Assistant Jin Pak		TIME COMPLETED:	12:17 PM

ALLEGATION(S):

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Resident's personal rights were violated

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced visit to the facility to deliver findings regarding the above-mentioned allegation. Upon arrival, LPA Haddadin was met by Office Assistant Jin Pak, who granted entry into the facility. LPA explained the purpose of the visit. Administrator Jane Kim was notified via phone and advised of the visit..
The Department received a complaint alleging that “Resident’s personal rights were violated.”
During the investigation, LPA conducted interviews with Resident 1 (R1), facility staff, residents, and the responsible party. LPA also reviewed R1’s file and facility records, including the Release of Client/Resident Medical Information form, Consent for Emergency Medical Treatment, Adult and Elderly Residential Facilities form signed by the responsible party, Physician’s Report, Resident Appraisal, and Admission Agreement.
{***CONTINUE 9099C***}

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2026

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-20260306135751

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 ROSEWOOD ASSISTED LIVING	FACILITY NUMBER: 306003448
	VISIT DATE: 06/02/2026

NARRATIVE

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Interviews with staff revealed that four of four staff interviewed stated they have not witnessed facility staff sharing residents’ personal or confidential information without authorization. Staff stated that they contact physicians or responsible parties when additional medical information is needed for resident care, including updated medication lists, clarification of physician’s orders, discharge paperwork, and changes in condition. Staff further stated they have not released confidential information regarding residents or resident records to unauthorized persons.
During an interview with R1, R1 stated that staff contacted R1’s physician without R1’s consent or knowledge. Interviews with residents revealed that four of four residents interviewed stated they have not experienced facility staff sharing confidential resident information without their consent.
Records reviewed revealed that R1’s Admission Agreement was signed and reviewed with the responsible party. The responsible party initialed the section acknowledging receipt of Resident Rights, which includes the resident’s or responsible party’s right to make decisions regarding medical treatment and advance health care directives. Record review further revealed that the responsible party signed the Consent for Emergency Medical Treatment form, which authorized Fullerton Rosewood Assisted Living to obtain emergency medical or dental care prescribed by a licensed physician for R1. The consent stated that such care may be provided under whatever conditions are necessary to preserve the well-being of the individual named. LPA also interviewed the responsible party, who confirmed being R1’s responsible party, confirmed signing the forms, and stated they had no concerns regarding the facility.
During the investigation, LPA observed that resident records were maintained in a secure location and were not accessible to the public.
Based on interviews and record review, the Department has investigated the allegation that “Resident’s personal rights were violated.” Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation occurred. Therefore, the allegation is unsubstantiated.
An exit interview was conducted with Office Assistant Jin Pak, and a copy of this report was provided.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2026

LIC9099 (FAS) - (06/04)

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