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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006112
Report Date: 05/26/2026
Date Signed: 05/26/2026 01:31:44 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
07/21/2025 and conducted by Evaluator Michael Tea
COMPLAINT CONTROL NUMBER: 22-AS-20250721112732
FACILITY NAME:ABK SWEET HOMECARE INC.FACILITY NUMBER:
306006112
ADMINISTRATOR:TRUONG, BRENDAFACILITY TYPE:
740
ADDRESS:10171 NORTHAMPTON AVETELEPHONE:
(714) 837-9198
CITY:WESTMINSTERSTATE: CAZIP CODE:
92683
CAPACITY:6CENSUS: 6DATE:
05/26/2026
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Kristine Truong, Lily NguyenTIME COMPLETED:
09:00 AM
ALLEGATION(S):
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- Facility failed to seek timely medical attention resulting in hospitalization
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michael Tea arrived on this day for the purpose of delivering findings into the above allegation. LPA met with Administrator (AD) Kristine Truong and Licensee (LE) Lily Nguyen. On July 21, 2025, the Orange County Adult and Senior Care Regional Office received a complaint alleging that the facility failed to seek timely medical attention resulting in hospitalization. During the investigation, the Department reviewed facility records, hospital records, incident reports, resident records, and conducted interviews with facility staff and witnesses. The investigation determined as follows:

Resident 1 (R1) suffered an unwitnessed fall at the facility on July 18, 2025, between approximately 4:30 AM and 5:00 AM. Facility staff found R1 on the floor and placed R1 back into bed after determining they did not complain of pain. Per physician report dated November 15, 2024, R1 has a diagnosis of severe Dementia.

(Complaint Investigation continued on LIC9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2026
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 5
Control Number 22-AS-20250721112732
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: ABK SWEET HOMECARE INC.
FACILITY NUMBER: 306006112
VISIT DATE: 05/26/2026
NARRATIVE
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Incident report record reviewed showed that staff did not immediately seek medical attention or notify R1’s family after the incident occurred. The facility’s own incident report documented that the family arrived to visit around 9:00 AM that same morning. During the investigation, R1’s family reported that they discovered bruising around R1’s forehead and left ear during their visit and questioned staff about the injuries. R1 was transported to the Hospital by their family after being advised by the facility to obtain a medical evaluation and x-ray if there was anything serious. Hospital records showed that R1 was admitted the same day with a diagnosis of fractured ribs, bruising to the forehead and ear, acute kidney injury, urinary tract infection, severe malnutrition, and delirium.

During the investigation, evidence also showed that R1 had a prior fall in April 2025 and had become increasingly unsteady and at risk for falls afterward. Staff acknowledged that R1 required frequent supervision and monitoring; however, no updated assessment or additional care plan was completed to address R1’s declining condition and increased fall risk.

Based on the information obtained during the investigation, the preponderance of evidence standard has been met. Therefore, the allegation mentioned above have been determined to be SUBSTANTIATED, meaning the complaint allegation is valid and that a violations has occurred. The following are cited by the California Code of Regulations, Title 22, Division 6.

A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49(f)

An exit interview was conducted and a copy of this report, LIC809-D, LIC421IM, appeal rights and confidential names list was provided to the facility.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
07/21/2025 and conducted by Evaluator Michael Tea
COMPLAINT CONTROL NUMBER: 22-AS-20250721112732

FACILITY NAME:ABK SWEET HOMECARE INC.FACILITY NUMBER:
306006112
ADMINISTRATOR:TRUONG, BRENDAFACILITY TYPE:
740
ADDRESS:10171 NORTHAMPTON AVETELEPHONE:
(714) 837-9198
CITY:WESTMINSTERSTATE: CAZIP CODE:
92683
CAPACITY:6CENSUS: 6DATE:
05/26/2026
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Kristine Truong, Lily NguyenTIME COMPLETED:
09:00 AM
ALLEGATION(S):
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9
- Facility did not report incident to resident's responsible party
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michael Tea arrived on this day for the purpose of delivering findings into the above allegation. LPA met with Administrator (AD) Kristine Truong and Licensee (LE) Lily Nguyen. On July 21, 2025, the Orange County Adult and Senior Care Regional Office received a complaint alleging that facility did not report an incident to resident’s responsible party. During the investigation, the Department reviewed facility records, hospital records, incident reports, resident records, and conducted interviews with facility staff and witnesses. The investigation determined as follows:

Resident 1 (R1) suffered an unwitnessed fall at the facility on July 18, 2025, between approximately 4:30 AM and 5:00 AM. Facility staff found R1 on the floor and placed R1 back into bed after determining they did not complain of pain.

(Complaint report continued on LIC9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 22-AS-20250721112732
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: ABK SWEET HOMECARE INC.
FACILITY NUMBER: 306006112
VISIT DATE: 05/26/2026
NARRATIVE
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Records showed that staff did not notify R1’s family immediately after the incident occurred. The facility’s own incident report documented that the family was informed when they arrived to visit around 9:00 AM. R1 was transported to the hospital by their family after being advised by the facility to obtain a medical evaluation and x-ray if there was anything serious. Hospital records showed that R1 was admitted the same day with a diagnosis of fractured ribs.

Although R1’s family was not immediately informed of the fall, regulatory requirements allow for seven days for the date of incident to provide a written report of incident to responsible party.

Based on the information obtained during the investigation, the allegation is deemed UNSUBSTANTIATED, meaning, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

An exit interview was conducted and a copy of this report and confidential names list were provided to the facility.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20250721112732
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: ABK SWEET HOMECARE INC.
FACILITY NUMBER: 306006112
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/27/2026
Section Cited
CCR
87465(g)
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Incidental Medical and Dental Care Services ... 9-1-1 shall be telephoned immediately if an injury or other circumstance has resulted in an imminent threat to a resident's health including an apparent life-threatening medical crisis. This requirement is not met as evidenced by:
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Facility will provide a statement of understanding regarding the regulation cited for and signed by staff and management. Facility will conduct an inservice training and provide proof to LPA by COB on POC due date.
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R1 had an unwitnessed fall in which medical attention was delayed for approximately 4 hours after which it was later discovered R1 suffered multiple rib fractures. This poses an immediate risk to the health and safety of residents 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.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5