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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374600289
Report Date: 02/23/2026
Date Signed: 02/23/2026 10:24:27 AM

Substantiated


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
10/23/2024 and conducted by Evaluator Janet Ngallo
COMPLAINT CONTROL NUMBER: 08-AS-20241023094424
FACILITY NAME:LEMON GROVE TERRACEFACILITY NUMBER:
374600289
ADMINISTRATOR:CELIA A. MENESESFACILITY TYPE:
740
ADDRESS:8554 CALLE NORTETELEPHONE:
(619) 463-6705
CITY:LEMON GROVESTATE: CAZIP CODE:
91945
CAPACITY:6CENSUS: 5DATE:
02/23/2026
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Caregiver Jesus ArenasTIME COMPLETED:
11:50 PM
ALLEGATION(S):
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9
Neglect/Lack of Supervision resulting in UTI.
Neglect/Lack of Supervision resulting in delayed medical care.
INVESTIGATION FINDINGS:
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On 02/23/2026, LPA Janet Ngallo conducted a subsequesnt visit to deliver findings regarding the above-mentioned allegations. LPA spoke with Caregiver Jesus Arenas and explained the purpose of the visit.

Regarding the allegation of Neglect/Lack of Supervision resulting in delayed medical care causing Resident 1 (R1) to have UTI, RP indicated that R1 was discovered with a clogged foley catheter, and the facility staff never called hospice to notify of the issue.

On 10/21/24, Hospice’s Aide (HA) visited R1 and found that R1's foley catheter was clogged, R1 had no urine output for over 24 hours. On the same day, HA conducted a follow-up visit and spoke to the administrator(ADM). ADM told HA that ADM have observed R1s change of condition on 10/19/24 and admitted that ADM noticed the clogged catheter on 10/20/24 but did not notify hospice about these concerns.

(Cont. on LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Janet Ngallo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2026
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 08-AS-20241023094424
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: LEMON GROVE TERRACE
FACILITY NUMBER: 374600289
VISIT DATE: 02/23/2026
NARRATIVE
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(Cont. from LIC 9099)

HA submitted a lab work for R1 on 10/21/24 and results on 10/22/24 revealed R1 was positive for UTI. HA stated that a clogged catheter, no urine output, and no intake could contribute to a UTI.

When ADM was interviewed, ADM mentioned not remembering calling hospice. One staff member (S1), confirmed that they observed a clogged catheter and reported it to the ADM.

The ADM neglected and/or failed to seek medical services for R1 when ADM acknowledged that R1 had a clogged catheter, with no urine output for 24 hours; and when R1s change of condition was observed. ADMs neglect and failure to seek immediate care for R1 resulted in R1s UTI.

At the time of the complaint inspection on 02/23/2026, licensee was informed that the incident is currently under review and a future civil penalty may apply based on Health and Safety Code § 1569.49.

Based on interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC 9099D. An Immediate Civil Penalty of $500.00 was also assessed (refer to the LIC421-IM page). An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Caregiver Jesus Arenas, whose signature below confirms receipt of these rights.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Janet Ngallo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 08-AS-20241023094424
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: LEMON GROVE TERRACE
FACILITY NUMBER: 374600289
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/24/2026
Section Cited
CCR
87465(a)(1)
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(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical...care appropriate to the conditions and needs of residents.
This was not met as evidenced by:
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Staff will provide proof of scheduled incidental medical care training with all staff within 24 hours to LPA via email. Training will be completed and submitted to LPA with sign-in sheet and training topic clearly noted via email by 03/13/2026
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Based on interviews and records review, Licensee’s neglect and failure to seek immediate care for R1 resulted in UTI which poses an immediate Health, Safety, or Personal Rights risk to persons in care.
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Type A
02/24/2026
Section Cited
CCR
87466
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The licensee shall ensure that residents are regularly observed for changes in physical, mental...and brought to the attention of the resident's physician and the resident's responsible person, if any.
This was not met as evidenced by:
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Staff will provide proof of scheduled change of condition training with all staff within 24 hours to LPA via email. Training will be completed and submitted to LPA with sign-in sheet and training topic clearly noted via email by 03/13//2026.
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Based on interviews and records review, Licensee failed to seek medical services for R1 when R1 had a clogged catheter and when R1s change of condition was observed which poses an immediate Health, Safety, or Personal Rights risk to persons 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: Lizzette Tellez
LICENSING EVALUATOR NAME: Janet Ngallo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2026
LIC9099 (FAS) - (06/04)
Page: 3 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
10/23/2024 and conducted by Evaluator Janet Ngallo
COMPLAINT CONTROL NUMBER: 08-AS-20241023094424

FACILITY NAME:LEMON GROVE TERRACEFACILITY NUMBER:
374600289
ADMINISTRATOR:CELIA A. MENESESFACILITY TYPE:
740
ADDRESS:8554 CALLE NORTETELEPHONE:
(619) 463-6705
CITY:LEMON GROVESTATE: CAZIP CODE:
91945
CAPACITY:6CENSUS: 5DATE:
02/23/2026
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Caregiver Jesus ArenasTIME COMPLETED:
11:50 PM
ALLEGATION(S):
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9
Neglect/Lack of Supervision resulting in stage 4 pressure injury.
Licensee refused medical care for resident.
Licensee restrained resident.
Licensee did not follow eviction procedures.
INVESTIGATION FINDINGS:
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On 02/23/2026, LPA Janet Ngallo conducted a subsequesnt visit to deliver findings regarding the above-mentioned allegation. LPA spoke with Caregiver Jesus Arenas and explained the purpose of the visit.

Regarding the allegation of Neglect/Lack of Supervision resulting in stage 4 pressure injury, Reporting party (RP) indicated that the resident (R1) is unable to reposition in bed and developed a stage 4 pressure injury.

During the investigation, staff members were interviewed, and records were reviewed.

Hospice Registered Nurse (RN) was interviewed and clarified Resident 1 (R1) was admitted to the facility with a pressure injury and hospice managed R1s treatment and wound care during their visits three or four times a week.

(Cont. on LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Janet Ngallo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 08-AS-20241023094424
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: LEMON GROVE TERRACE
FACILITY NUMBER: 374600289
VISIT DATE: 02/23/2026
NARRATIVE
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(Cont. from LIC 9099)

Furthermore, RN confirmed that the administrator (ADM) was trained and educated in treating and dressing the wound during the days that hospice did not visit.

For the allegation of Licensee refused medical care for resident, RP stated that when R1 returned to facility, R1 had another fall but licensee declined a visit from hospice.

According to the records, a notation stating that ADM called hospice about the fall, voiced no injury for R1, refusing help but yelling out for help. ADM stated that hospice is always called every time R1 has a fall and doesn’t deny help for R1.

Regarding the allegation of Licensee restrained resident, RP indicated that staff are using chairs to block the residents’ bed to prevent falls.

According to ADMs interview, it was stated that chair was used to assist R1 when staff is helping the R1and not restrain. R1 has a waiver to not use bed rails.

For the allegation of Licensee did not follow eviction procedures, RP said the ADM wants the resident moved out to another facility but has not issued an eviction notice to R1s responsible parties.

Based on the records, initially ADM didn’t want to accept R1 back after R1 was discharged from a hospital visit. ADM was educated about submitting a notice for eviction. ADM accepted R1 back but did not give notice about eviction and continued care for R1.

Based on interviews and records review, the department has determined that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.'

An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Caregiver Jesus Arenas, whose signature below confirms receipt of these rights.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Janet Ngallo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5