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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 372004894
Report Date: 06/03/2025
Date Signed: 06/03/2025 04:10:16 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/16/2022 and conducted by Evaluator Dang Nguyen
COMPLAINT CONTROL NUMBER: 08-AS-20220216163808
FACILITY NAME:TIERRASANTA VERNANEL CARE HOMEFACILITY NUMBER:
372004894
ADMINISTRATOR:PANAO, NELLY, D.FACILITY TYPE:
740
ADDRESS:11085 ZAGALA COURTTELEPHONE:
(858) 569-1870
CITY:SAN DIEGOSTATE: CAZIP CODE:
92124
CAPACITY:6CENSUS: 2DATE:
06/03/2025
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Licensee Nelly PanaoTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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-Licensee did not protect resident from another resident’s sexual abuse.
-Licensee did not safeguard resident personal property.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced subsequent visit to deliver findings regarding the above prior complaint allegations. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Licensee Nelly Panao.

The Complainant alleged that Licensee did not protect Resident #2 (R2) from being sexually abused by Resident #1 (R1), and that Licensee did not safeguard resident personal property. [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] CCLD’s investigation involved multiple unannounced facility tours/welfare check and interviews of relevant residents, staff, and outside sources. The Department also reviewed pertinent San Diego Police Department (SDPD) records and facility care records.

[CONTINUED ON LIC 9099-C, 1 of 4]
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025
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 8
Control Number 08-AS-20220216163808
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: TIERRASANTA VERNANEL CARE HOME
FACILITY NUMBER: 372004894
VISIT DATE: 06/03/2025
NARRATIVE
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[CONTINUED FROM LIC 9099]

Staff interviews aligned to show: During the complaint allegation time frame, Staff #1 (S1) was the primary caregiver at the facility. Staff #2 (S2) was the only other caregiver, but they worked far fewer hours. They also showed that R1, who had lived at the facility since mid-2020, was diagnosed with Dementia and tended to wander around the facility and its outside yards, sometimes naked, requiring staff redirection. R1 would also open housemates’ bedroom doors and stare at them.

R1’s LIC602 Physician’s Report confirmed their dementia and wandering diagnoses. Interviews of staff, corroborated by police records and California’s Megan’s Law database, showed R1 was also a Registered Sex Offender (RSO). Meanwhile, R2, who moved into the facility on the evening of 09/17/2021, was vision-impaired but retained 10% eyesight in their right eye. R2 was diagnosed with major depressive disorder with psychotic features. However, per their LIC602 Physician’s Report, their doctor determined that R2 was not confused/disoriented, was able to follow instructions, and was able to communicate their needs.

LPA met R2, determining that they were alert, oriented, and coherent enough to be qualified as a reliable historian. Per interview of R2: Around 6:00 AM or 7:00 AM on 09/18/2021 (which was their first morning living at the facility), they were sitting on the edge of their bed when R1 entered their bedroom and sat beside them. R1 solicited R2 for sex, which R2 refused. R1 then repeatedly touched R2 between their legs and squeezed R2’s breasts. R2 cried out for help. This went on for 20-30 minutes before an unknown person came to the room and redirected R1 away. R2 said there was a separate day during February 2022 when R1 tried to force their way into R2’s bedroom. Resident #3 (R3), who was visiting with R2 at the time, used their body weight to hold the door closed, until R1 gave up and walked away. Interview of R3 corroborated that second event.

LPA did not interview R1. R1 had moved out by the time the complaint was filed with CCLD. Subsequent SDPD records showed their police officers tried interviewing R1, but quickly concluded R1 was too disoriented/confused to be a reliable historian.


[CONTINUED ON LIC 9099-C, 2 of 4]
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 08-AS-20220216163808
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: TIERRASANTA VERNANEL CARE HOME
FACILITY NUMBER: 372004894
VISIT DATE: 06/03/2025
NARRATIVE
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[CONTINUED FROM LIC 9099-C, 1 of 4] In their own interviews, neither S1 nor S2 heard/witnessed any part of the 09/18/2021 incident between R1 and R2. S1 and S2 each denied being the person who redirected R1 away from R2. S1 said R2 told them about the incident shortly after, but S1 did not believe it really occurred, because they knew R2 to be nearly blind and to sometimes experience hallucinations. S1’s description of the incident from R2 closely matched what R2 told LPA. S1 did not report the alleged incident to either R1’s responsible person (RP) or R2’s RP, or to CCLD, the Long-Term Care Ombudsman (LTCO), or SDPD, as required. [Not meeting reporting requirements will be addressed in a separate case management visit report.]

At the time of the incident, the other residents in care were Resident #3 (R3), Resident #4 (R4), and Resident #5 (R5). LPA met each, determining that R3 and R4 were alert, oriented, and coherent enough to be reliable historians, while R5’s cognition was less strong. Per their interviews, these residents did not personally hear/witness the 09/18/2021 incident between R1 and R2. They denied themselves being physically/sexually abused by R1. However, R3 stated that R1 often prowled the facility’s yards at night, and on “half a dozen” nights tried unsuccessfully to open the side door which led from the outside directly into R3’s bedroom, being deterred when R3 yelled at them. R4 said R1 made vulgar sexual comments towards them personally. R4 confirmed that R1 on multiple nights tried unsuccessfully to enter their own bedroom from the outside using their side door. R4 said they made S1 aware of this troubling behavior. R4 also corroborated the day that R1 tried to force their way into R2’s bedroom and R4 stopped them.

S1 told LPA they knew R1’s behaviors made multiple other residents uncomfortable, but S1 did not issue a 30-day eviction notice for R1 or inform their RP of their housemates' allegations against R1. Interviews of S1 and residents, corroborated by police records, showed: Multiple residents directly approached R1’s RP to inform them of their individual fears/concerns regarding R1. This was also how R1’s RP became aware of the 09/18/2021 incident between R1 and R2. Upon receiving this information, R1’s RP notified SDPD, who on 02/11/2022 visited the facility to open an investigation. Police wrote that R2 and R4 lived in “extreme fear” of R1, with R2 having to barricade their bedroom door at night and R4 losing sleep. With R1’s impaired cognition, police officers deemed R1 a “danger to others” and that same day arranged for R1 to be transported to the hospital on a Welfare and Institutions Code 5150 psychiatric hold. From there, R1’s RP arranged for R1 to discharge elsewhere; R1 did not return to Tierrasanta Vernanel Care Home. [CONTINUED ON LIC 9099-C, 2 of 4]
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 08-AS-20220216163808
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: TIERRASANTA VERNANEL CARE HOME
FACILITY NUMBER: 372004894
VISIT DATE: 06/03/2025
NARRATIVE
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[CONTINUED FROM LIC 9099-C, 1 of 4] Per the police report: R1 was so disoriented to other persons that R1 previously made sexual comments towards their own RP and tried to grope them too. The statements S1, R2, R3, and R4 individually gave to SDPD were consistent with their later statements to CCLD.

During questioning, S1 told LPA that former Resident #6 (R6), who had moved out prior to the complaint time frame, previously told a hospice agency staff that someone had come into their bedroom and touched their legs and chest. S1 stated they did not witness this incident and did not believe it really occurred, since they claimed R6 had Dementia and sometimes experienced hallucinations. S1 did not report the alleged incident to either R6’s responsible person (RP), CCLD, the Long-Term Care Ombudsman (LTCO), or SDPD, as required. S1 denied there being other instances of possible abuse between R1 and R6. CCLD subsequently reviewed a series of dated handwritten progress notes written by S1, which revealed: On 06/13/2021, S1 personally witnessed R1 inside R6’s bedroom, touching R6’s face and breast without their consent, requiring S1 to redirect R1 away from R6. There were also two successive incidents when R1 entered R6’s bedroom (unwitnessed by S1 but which R6 later reported to them): R6 said on 07/30/2021, R1 was touching them without their consent. R6 said on 09/13/2021, R1 removed R1's own pants and exposed their genitals to R6, who shoved R1 away from them. [False/Misleading Statements and Not Meeting Reporting Requirements will be addressed in a separate case management visit report.]

LPA did not interview R6. They had already moved out by the time the complaint was filed with CCLD, and by the time LPA established contact with R6’s RP, he learned that R6 had since died. R6’s RP confirmed not being informed of allegations/instances of physical/sexual abuse against R6. R6’s RP also denied R6 having Dementia or hallucinations during the time they lived at the facility. Per R6's LIC602 Physician's report, R6 did not have either Mild Cognitive Impairment or Dementia. Their doctor also determined that R6 was not confused/disoriented, was able to communicate their needs, and was able to follow instructions.

R4 told LPA that R1 stole $80 from their purse. R4 said they told S1 about this. S1 said they later checked R1’s pants pockets during laundry but never found money. R3 told LPA that R1 had taken their own belongings on several occasions, most of which resulted in them recovering the missing items. However, there was a bottle of mouthwash and two sweaters which R3 never got back. Records review and manager interview showed: Licensee did not maintain a written Theft and Loss Record for the facility, as required. [CONTINUED ON LIC 9099-C, 4 of 4]
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 08-AS-20220216163808
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: TIERRASANTA VERNANEL CARE HOME
FACILITY NUMBER: 372004894
VISIT DATE: 06/03/2025
NARRATIVE
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[CONTINUED FROM LIC 9099-C, 3 of 4] Licensee also did not maintain a written Personal Property Inventory for R1 through R6, as required. Licensee did not report these losses to the responsible persons for either R1 or R3, nor compensate/reimburse the residents for these losses.

Based on records and interviews, a preponderance of evidence exists to prove the Licensee did not protect a resident (R2 and R6) from another resident’s (R1’s) sexual abuse, and that Licensee did not safeguard resident personal property. Both allegations are therefore Substantiated, and two (2) deficiencies were cited for them per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D page). Plans of Correction were jointly developed with the Licensee.

An exit interview was conducted with Licensee Nelly Panao, to whom a copy of this report, the LIC 9099-D page, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 08-AS-20220216163808
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: TIERRASANTA VERNANEL CARE HOME
FACILITY NUMBER: 372004894
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/03/2025
Section Cited
CCR
87468.2(a)(8)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: “(a) …residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (8) To be free from… mental, physical, or sexual abuse.” This requirement was not met, as evidenced by:
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By the date CCLD received the complaint, R1 had already moved out of the facility, resolving the immediate risk. Licensee agreed to have all current staff receive remedial education on Resident’s Personal Rights (as articulated in LIC613-C), Incident Reporting Requirements (as articulated in CCR 87211) and California Mandated Reporting Requirements (as articulated in SOC341A) through a third-party training source, and to E-mail proof of completion to LPA, by 07/03/2025.
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Based on records and interviews, Licensee did not ensure that 2 of 6 residents (R2 and R6) were free from, mental, physical, or sexual abuse. This posed an immediate safety and personal rights risk to persons in care.
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Type B
07/03/2025
Section Cited
CCR
87218(a)
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87218 Theft and Loss: “(a) The licensee shall ensure an adequate theft and loss program as specified in Health and Safety Code Section 1569.153.” This requirement was not met, as evidenced by:
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As of the date of deficiency issuance, R1 through R6 no longer live at the facility. Licensee agreed to: a) gather LIC621 Personal Property Inventory forms for all current residents, b) prepare and maintain one ongoing LIC9060 Theft and Loss Record, c) write and post a Theft and Loss Policy (with investigative procedures), and d) train all current staff on the Theft and Loss Policy. Licensee agreed to E-mail to LPA completed/signed copies of the LIC621’s, the LIC9060, the Theft and Loss Policy, and the staff training sign-in sheet, by the POC due date.
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Based on records and interviews, Licensee did not ensure an adequate theft and loss program as specified in Health and Safety Code Section 1569.153. This posed a potential personal rights risk to 6 of 6 residents (R1 through R6) 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: Simon Jacob
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/16/2022 and conducted by Evaluator Dang Nguyen
COMPLAINT CONTROL NUMBER: 08-AS-20220216163808

FACILITY NAME:TIERRASANTA VERNANEL CARE HOMEFACILITY NUMBER:
372004894
ADMINISTRATOR:PANAO, NELLY, D.FACILITY TYPE:
740
ADDRESS:11085 ZAGALA COURTTELEPHONE:
(858) 569-1870
CITY:SAN DIEGOSTATE: CAZIP CODE:
92124
CAPACITY:6CENSUS: 2DATE:
06/03/2025
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Licensee Nelly PanaoTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Licensee did not protect resident from being hit by another resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced subsequent visit to deliver a finding regarding the above prior complaint allegation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Licensee Nelly Panao.

The Complainant alleged Licensee did not protect Resident #3 (R3) from being hit by Resident #1 (R1). [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] CCLD’s investigation involved multiple unannounced facility tours/welfare check and interviews of relevant residents, staff, and outside sources. The Department also reviewed pertinent San Diego Police Department (SDPD) records and facility care records.


[CONTINUED ON LIC 9099-C]
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 08-AS-20220216163808
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: TIERRASANTA VERNANEL CARE HOME
FACILITY NUMBER: 372004894
VISIT DATE: 06/03/2025
NARRATIVE
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[CONTINUED FROM LIC 9099-A]

Interviews of staff and residents, and SDPD records, generally aligned to show: On 02/02/2022, Resident #2 (R2) gave a packet of cookies to R3. R1, who was diagnosed with Dementia, claimed that the cookies belonged to themselves. This was the basis for an ensuing argument between R1 and R3, which took place in the facility’s dining room. R1 hit R3 with a cane, once on the shoulder, and once on the head. Staff #1 (S1) responded quickly to break up the altercation, separating R1 from R3 until police arrived. SDPD subsequently transported R1 to the hospital on a Welfare and Institutions Code 5150 hold. R3 said the hits were not hard and denied experiencing pain or injury.

Based on records and interviews, a preponderance of evidence does not exist to support that Licensee did not protect R3 from being hit by R1. The allegation is therefore Unsubstantiated, and no deficiency was cited for it.

An exit interview was conducted with Licensee Nelly Panao, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025
LIC9099 (FAS) - (06/04)
Page: 8 of 8