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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374600276
Report Date: 10/15/2025
Date Signed: 10/16/2025 03:11:24 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
06/23/2025 and conducted by Evaluator Liliana Silveira
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20250623154810
FACILITY NAME:CASA DE CASTROFACILITY NUMBER:
374600276
ADMINISTRATOR:CHERYL M. CASTROFACILITY TYPE:
740
ADDRESS:5581 CHATTANOOGATELEPHONE:
(619) 267-3934
CITY:SAN DIEGOSTATE: CAZIP CODE:
92139
CAPACITY:6CENSUS: 5DATE:
10/15/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator Cheryl CastroTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff took resident's phone away.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Liliana Silveira conducted an unannounced visit to continue a complaint investigation visit and to deliver findings. LPA Silveira introduced themselves, disclosed the purpose of the visit and was granted entry into the facility by caregiver Josefina “Josie” Wilkins. Licensee Cheryl Castro arrived a short time after.

The Department’s investigation consisted of interviews and a records review. On June 23, 2025, it was alleged that staff took Resident #2’s (R2’s) phone away. A Department interview with Resident #2 (R2) revealed that Staff #1 (S1) had taken R2’s cell phone away. R2 stated that they would ask staff to charge the cell phone often. R2 also admitted that the phone would go “missing” because R2 was confused and would misplace it. An interview with S1 revealed that due to health issues, R2 was continuously dropping their cell phone and losing it. S1 stated that they held the phone for R2 to keep it safe and there were no intentions to take the phone away from R2. (CONTINUED ON NEXT PAGE, LIC 809C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Liliana Silveira
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025
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 5
Control Number 08-AS-20250623154810
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: CASA DE CASTRO
FACILITY NUMBER: 374600276
VISIT DATE: 10/15/2025
NARRATIVE
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(CONTINUED FROM PAGE 1, LIC 9099)

A Department interview with Staff #2 (S2) revealed that they were unaware of R2’s phone being taken away. Department interviews with three other residents and a resident’s Responsible Relative revealed that there were no concerns regarding staff taking personal items from residents. There was not enough evidence to support this allegation.

Due to a lack of corroborating evidence, the allegation that staff took R2’s phone away is unsubstantiated. Although the allegation may have happened or may be valid, there is not a preponderance of evidence to prove the alleged violation occurred, therefore, the allegation is unsubstantiated.

This report was discussed with Cheryl Castro. A copy of this report, along with Licensee/Appeal Rights, (LIC 9058 03/22) were provided. Signature below acknowledges receipt of the documents.

*NOTE: LPA left for a 1 hour lunch break and to type all reports related to this complaint.

SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Liliana Silveira
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025
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
SAN DIEGO RO, 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
06/23/2025 and conducted by Evaluator Liliana Silveira
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20250623154810

FACILITY NAME:CASA DE CASTROFACILITY NUMBER:
374600276
ADMINISTRATOR:CHERYL M. CASTROFACILITY TYPE:
740
ADDRESS:5581 CHATTANOOGATELEPHONE:
(619) 267-3934
CITY:SAN DIEGOSTATE: CAZIP CODE:
92139
CAPACITY:6CENSUS: 5DATE:
10/15/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator Cheryl CastroTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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2
3
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9
Staff restrained resident to their bed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Liliana Silveira conducted an unannounced visit to continue a complaint investigation visit and to deliver findings. LPA Silveira introduced themselves, disclosed the purpose of the visit and was granted entry into the facility by caregiver Josefina “Josie” Wilkins. Licensee Cheryl Castro arrived a short time after.

The Department’s investigation consisted of observations, interviews and a records review. On June 23, 2025, it was alleged that staff restrained Resident #1 to their bed. An interview with an outside source revealed that Resident #2 (R2) had witnessed staff restraining Resident #1 (R1) to their bed in the evenings. The Department conducted an interview with R2 who stated that they shared a room with R1 and witnessed staff restraining R1 to their bed at nighttime. A Department interview with R1’s Responsible Relative (RR) revealed that RR had requested the facility to restrain R1 in the evening to avoid falls. R1 had a recent history of falls and had broken a hip due to a fall. (CONTINUED ON NEXT PAGE, LIC 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Liliana Silveira
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025
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 08-AS-20250623154810
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: CASA DE CASTRO
FACILITY NUMBER: 374600276
VISIT DATE: 10/15/2025
NARRATIVE
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(CONTINUED FROM FIRST PAGE, LIC 9099A)

RR also stated that R1’s Primary Care Physician (PCP) had approved the use of restraints on R1 to avoid falls. A records review of R1’s Physician’s Report, dated 11/21/2023, revealed that the PCP approved a “soft tie” for R1 while R1 was seated in a wheelchair to prevent falls. There was no other indication regarding the approval of restraints for a bed. An interview with the Licensee/Administrator confirmed that RR had requested the restrain from the facility and the Administrator believed that the restraint allowed on the Physician’s Report extended to use on the bed.

Interviews with two care staff also revealed that they were restraining the resident to the bed and demonstrated the item used to restrain R1. Finally, an interview with R1 revealed that R1 recognized the items used to restrain them and was clearly able to demonstrate the procedure used by staff to restrain them to the bed. There was enough evidence to determine that this allegation is substantiated.

Based on the evidence obtained from interviews, observations and a records review, the complaint allegation is substantiated. A substantiated finding means the allegation is valid because the preponderance of the evidence standard has been met.

A deficiency is cited per Title 22 California Code of Regulation. LPA Silveira conducted an exit interview with Cheryl Castro to whom a copy of this report, the LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided. Signature below confirms receipt of the reports.

SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Liliana Silveira
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 08-AS-20250623154810
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: CASA DE CASTRO
FACILITY NUMBER: 374600276
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/15/2025
Section Cited
CCR
87608(a)(3)
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87608 Postural Supports (a)(3): A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. This requirement was not met, as evidenced by:
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The Administrators and Caregivers will complete training on postural supports and resident personal rights by 10/29/25.
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 Based on a records review and interviews, the Licensee restrained Resident #1 to their bed without a physician's order, which posed a potential safety risk to 1 out of 4 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: Robyn Clark
LICENSING EVALUATOR NAME: Liliana Silveira
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5