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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374600823
Report Date: 01/23/2026
Date Signed: 01/23/2026 12:07:05 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
09/30/2025 and conducted by Evaluator Ramin Hashemi
COMPLAINT CONTROL NUMBER: 08-AS-20250930153300
FACILITY NAME:HILLSIDE GARDEN RCFEFACILITY NUMBER:
374600823
ADMINISTRATOR:JASNA POPOVICHFACILITY TYPE:
740
ADDRESS:4892 HILLSIDE DRIVETELEPHONE:
(760) 730-3800
CITY:CARLSBADSTATE: CAZIP CODE:
92008
CAPACITY:6CENSUS: 5DATE:
01/23/2026
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Licensee Jasna PopovichTIME COMPLETED:
12:40 PM
ALLEGATION(S):
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Resident developed stage 4 pressure injury due to staff neglect
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ramin Hashemi conducted an unannounced visit to deliver findings regarding the above complaint allegation. LPA introduced themselves and disclosed the purpose of the visit to Licensee Jasna Popovich.

On 09/30/2025, it was alleged "Resident developed stage 4 pressure injury due to staff neglect." The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review.

Regarding the allegation, "Resident developed stage 4 pressure injury due to staff neglect.", it was alleged that Resident 1 (R1) had developed a stage 4 wound, staff had knowledge of the wound, and staff did not seek appropriate medical attention and wound care.

(Continued on LIC9099, Page 2)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Ramin Hashemi
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 1
Control Number 08-AS-20250930153300
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: HILLSIDE GARDEN RCFE
FACILITY NUMBER: 374600823
VISIT DATE: 01/23/2026
NARRATIVE
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(Continued from IC9099, Page 1)

Staff interviews revealed when R1 was originally admitted to the facility, they arrived with a rash and blisters. Staff confirmed that the rash eventually cleared up after a couple weeks with proper bathing and an unknown cream Contact 10 (C10) applied to R1's rash. According to staff, R1 was never evaluated by a medical expert for their skin conditions and staff admitted they treated R1’s blisters under the direction of C10 or on their own. One of the staff members said staff would gently put pressure on the blister to pop them and drain the fluid, so they would not get bigger. Staff stated that approximately one year ago, a larger blister developed in between R1’s buttock cheeks (coccyx). During conversations with Contact 1 (C1) and Contact 3 (C3), C3 stated they were concerned about the blister and asked C10 several times to have R1 evaluated by hospice or home health to get care for the blister. Facility staff made all responsible parties aware that staff were not qualified to care for the blister. None of the staff have any official training treating pressure injuries and the blister on R1’s coccyx was never evaluated by a medical expert.

Records review revealed that On 8/31/2025, R1 was transported to the hospital to be evaluated for a possible UTI. Medical records indicated R1’s coccyx wound was first observed on 9/2/2025, sometime after 9:00 PM when R1 was given a bed bath. However, there is no documentation the wound was staged at that time. The wound was evaluated by a wound care specialist nurse the following morning 9/3/2025, at 7:30 AM and diagnosed as a stage three pressure injury.

Outside Source interviews revealed that Contact 15 (C15) and Contact 6 (C6) agreed that R1’s coccyx pressure injury could have developed from what the Facility staff member observed on the morning of 8/31/2025 when changing R1’s diaper to a stage three pressure injury on 9/3/2025, at 7:30 AM, if it went unnoticed and untreated.

Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Licensee Jasna Popovich, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Ramin Hashemi
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2026
LIC9099 (FAS) - (06/04)
Page: 1 of 1