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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374601185
Report Date: 08/22/2023
Date Signed: 08/22/2023 11:02:12 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 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
08/08/2023 and conducted by Evaluator Daniel Pena
COMPLAINT CONTROL NUMBER: 08-AS-20230808115835
FACILITY NAME:SERRA MESA GUESTS HOME, LLCFACILITY NUMBER:
374601185
ADMINISTRATOR:EVELYN MAGNO SALAZARFACILITY TYPE:
740
ADDRESS:8693 CELESTINE AVENUETELEPHONE:
(858) 576-9701
CITY:SAN DIEGOSTATE: CAZIP CODE:
92123
CAPACITY:6CENSUS: 5DATE:
08/22/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Alma Lim, CaregiverTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Unlawful eviction
INVESTIGATION FINDINGS:
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On 8/22/2023 at about 9:30 AM, Licensing Program Analyst (LPA) Daniel Pena, conducted an unannounced complaint visit to the facility. After introducing and identifying himself, LPA met with Caregiver, Alma Lim and discussed the purpose of the visit which was to deliver investigative findings for this complaint. LPA also spoke with Licensee, Evelyn Salazar by facility telephone and explained to her the findings of the investigation.

On 8/8/2023, it was alleged the facility unlawfully evicted Resident 1 (R1). Reporting showed, as a result of aggressive behavior, R1 was transported to the Emergency Department for evaluation. R1 was subsequently psychiatrically cleared and treated for a separate condition. When the hospital advised the facility that R1 was cleared, staff refused to allow R1 to return.

The Department’s investigation consisted of facility inspections, staff and outside source interviews and a review of facility and resident records. Interviews returned an admission that the facility refused to accept R1 back because the resident displayed aggression towards staff. The facility admittedly did not serve
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Daniel Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023
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 3
Control Number 08-AS-20230808115835
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: SERRA MESA GUESTS HOME, LLC
FACILITY NUMBER: 374601185
VISIT DATE: 08/22/2023
NARRATIVE
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R1, their responsible person, nor CCLD with a notice that R1 was being evicted. Admittedly, the facility also did not request or receive CCLD approval to proceed with R1’s eviction.

Based on record reviews, interviews with outside sources and an admission by facility personnel, the facility evicted R1. However, the facility did not adhere to Title 22, Eviction Procedures when executing R1’s eviction. The Department’s investigation produced sufficient evidence that the Preponderance of Evidence standard has been met. Therefore, the allegation is Substantiated.

California code of Regulations, Title 22, Division 6 & Chapter 1 is being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with the Licensee Rights (LIC 9058 01/16) were provided to Caregiver, Lim whose signature below confirms receipt of these rights.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Daniel Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20230808115835
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: SERRA MESA GUESTS HOME, LLC
FACILITY NUMBER: 374601185
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/23/2023
Section Cited
CCR
80068.5
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Eviction Procedures. The notice to quit shall state the reasons for the eviction, with specific facts supporting the reason for the eviction including the date, place, witnesses, if any, and circumstances. This requirement is not met as evidenced by:
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Licensee agrees to contract for vendorized Personal Rights and Eviction Procedures training for all staff. Licensee to submit receipt of contract to CCLD by 8/23/2023 and wrtiten evidence of completed training by POC date of 9/23/2023.
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Based on interviews and record review the licensee did not issue a lawful eviction notice for 1 out of 4 residents [R1] in care which posed a potential personal rights violation.
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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: Daniel Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3