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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374601334
Report Date: 07/09/2025
Date Signed: 07/09/2025 12:06:17 PM

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
10/23/2023 and conducted by Evaluator Tiffany Holmes
COMPLAINT CONTROL NUMBER: 08-AS-20231023085742
FACILITY NAME:SERRA MESA GUESTS HOME III, LLCFACILITY NUMBER:
374601334
ADMINISTRATOR:SALAZAR, EVELYNFACILITY TYPE:
740
ADDRESS:3008 MELBOURNE DRTELEPHONE:
(858) 277-6515
CITY:SAN DIEGOSTATE: CAZIP CODE:
92123
CAPACITY:6CENSUS: 5DATE:
07/09/2025
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Joy Singson, CaregiverTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Facility did not seek resident timely medical attention.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced complaint visit to deliver findings regarding the above mentioned allegations. LPA was greeted by, identified herself to, and explained the purpose of the visit and the basic elements of the complaint with Joy Singson, Caregiver.

During today’s visit, LPA observed residents in care and interviewed residents and staff.

The Department’s investigation consisted of interviews with residents, staff, and outside sources, records review, and a tour of the facility. It was alleged that the facility did not seek timely medical attention. Interviews and review of medical records revealed that Resident 1 (R1) had an unwitnessed fall at the facility, which resulted in them sustaining a broken femur, and the facility failed to seek timely medical. Interviews and documents reviewed revealed that between October 11, 2023, and October 18, 2023, hospice and facility staff stated R1 would complain of leg pain, but the pain R1 expressed was similar to the pain they have had since the beginning of admission and interviews revealed they didn’t think it was anything serious
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2025
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 6
Control Number 08-AS-20231023085742
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: SERRA MESA GUESTS HOME III, LLC
FACILITY NUMBER: 374601334
VISIT DATE: 07/09/2025
NARRATIVE
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Interviews revealed that R1 remained at Serra Mesa Guest Home III for a week with noticeable pain and significant signs of bruising without being assessed and being seen by a competent doctor to rule out any internal injuries that could not be seen. Interviews revealed that on October 11, 2023, around 4:30 am, R1 rolled out of bed and onto their knees with staff assisting R1 back to the bed shortly after. Interviews and record review revealed that the hospice nurse came to examine R1 around 12:30 PM and stated that R1 showed no signs of pain and had no visible bruising. Interviews revealed between October 11, 2023, and October 16, 2023, that hospice staff and staff stated R1 would complain of leg pain but again the pain they expressed was similar to the pain R1 had since the beginning of admission. Interviews revealed that facility staff and hospice staff stated R1 started showing some visible signs of purple discoloration on their lower extremities hours after the fall and through the date of October 16, 2023. Interviews revealed that staff administered Tylenol to help with the pain from the date of the fall up until R1 went to the hospital. On October 14, 2023, interviews with staff revealed they noticed R1 showing different signs of pain with facial grimaces and contacted hospice. Interviews with hospice staff stated there were no new onset signs of pain and continued administering Tylenol. On October 16, 2023, hospice and staff stated R1 still was showing signs of pain, this time with groaning sounds, and decided to contact R1's son regarding administering morphine to R1 for pain. Interviews revealed the son refused the morphine and preferred R1 get X-rays before giving R1 any narcotics. Interviews revealed that on October 17, 2023, an in-house X-ray technician went to the facility to take X-rays of R1's legs, and on October 18, 2023, results came back stating R1 had a broken leg femur. Interviews revealed that on October 18, 2023, R1 was transported to Kaiser Hospital and did not return to the facility due to the son’s wishes for R1 not to return.

Based on the information collected during the investigation, there is enough evidence to support the allegation of the facility failing to seek timely medical; therefore, the allegation is deemed Substantiated. The allegation is valid because the preponderance of the evidence standard has been met. This report has been discussed and a copy was provided to Joy Singson, Caregiver at the conclusion of the visit.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Citations on this Visit Report are Under Appeal!

Control Number 08-AS-20231023085742
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: SERRA MESA GUESTS HOME III, LLC
FACILITY NUMBER: 374601334
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
07/23/2025
Section Cited
CCR
87465(a)(1)
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A plan for incidental medical care shall be developed by each facility. The plan shall encourage routine medical care and provide for assistance in obtaining such care by... The licensee shall arrange or assist in arranging for medical care appropriate to the conditions and needs or residents...
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Administrator agreed to have all staff attend a training on Timely Medical Attention for Residents in care. Proof of training will be provided by POC due date of 07/23/2025.

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This requirement was not met as evidenced by: Based on interviews and records review, the licensee delayed medical attention for 1 of 6 residents (R1) that expressed pain for 7 days which posed an immediate health, safety or personal 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: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6
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
10/23/2023 and conducted by Evaluator Tiffany Holmes
COMPLAINT CONTROL NUMBER: 08-AS-20231023085742

FACILITY NAME:SERRA MESA GUESTS HOME III, LLCFACILITY NUMBER:
374601334
ADMINISTRATOR:SALAZAR, EVELYNFACILITY TYPE:
740
ADDRESS:3008 MELBOURNE DRTELEPHONE:
(858) 277-6515
CITY:SAN DIEGOSTATE: CAZIP CODE:
92123
CAPACITY:6CENSUS: 5DATE:
07/09/2025
ANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Joy Singson, CaregiverTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Neglect to resident resulting in serious bodily injury
Facility did not follow reporting requirements.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced complaint visit to deliver findings regarding the above mentioned allegation. LPA was greeted by, identified herself to, and explained the purpose of the visit and the basic elements of the complaint with Joy Singson, Caregiver.

During today’s visit, LPA observed residents in care and interviewed residents and staff.

The Department’s investigation consisted of interviews with residents, staff, and outside sources, a records review, and a tour of the facility. It was alleged that neglect to resident resulting in serious bodily injury. Interviews and review of medical records revealed that Resident 1 (R1) was admitted into Serra Mesa Guest Home III on Hospice care from Together Hospice on October 7,2023. Interviews revealed that facility staff and Hospice staff state that during admission, R1 had always complained of leg pain and was very combative, anxious, and had sundowners. Interviews revealed that on October 11, 2023, around 4:30 am, R1 rolled out of bed and onto their knees, and Staff one (S1) and Staff two (S2) quickly went to assist R1
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2025
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 6
Control Number 08-AS-20231023085742
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: SERRA MESA GUESTS HOME III, LLC
FACILITY NUMBER: 374601334
VISIT DATE: 07/09/2025
NARRATIVE
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S1 stated that during the NOC shift, R1 was restless and the only resident who wouldn’t sleep through the night. Interviews with S1 stated that on October 11, 2023, during their NOC shift, they stayed with R1 by the bedside most of the night. Interviews with S1 revealed that their shift was due to end, and they left R1's room for about 15 minutes to change another resident’s diaper. Interviews revealed S1 stated when they came back to R1's room, S1 found R1 on their knees next to the bed. Interviews revealed that S1 and S2 both assessed R1 and that R1 complained of no pain and had no visible injuries or bruising. Interviews revealed that staff notified the administrator, and the administrator contacted the hospice care agency and R1's family around 7 am. Interviews and record review revealed that the hospice nurse came to examine R1 around 12:30 PM and also stated that R1 showed no signs of pain and had no visible bruising. Interviews revealed between October 11, 2023, and October 16, 2023, that hospice and staff stated R1 would complain of leg pain, but the pain they expressed was similar to the pain R1 had since the beginning of admission. Interviews revealed that the facility staff and hospice staff stated R1 had started showing some visible signs of purple discoloration on their lower extremities hours after the fall and through the date of October 16, 2023. Interviews revealed that staff administered Tylenol to help with the pain. On October 14, 2023, interviews with staff revealed that is when they noticed R1 showing different signs of pain with facial grimaces and contacted hospice. Interviews with Hospice stated there were no new onset signs of pain and continued administering Tylenol. On October 16, 2023, hospice and staff stated R1 still was showing signs of pain, this time with groaning sounds, and decided to contact R1's son to see if it was okay to administer morphine to R1 for pain. Interviews revealed the son refused the morphine and stated that he preferred moving forward with x-rays before giving R1 any narcotics. On October 17, 2023, an in-house X-ray technician went to the facility to take X-rays of R1's legs, and on October 18, 2023, results came back stating R1 had a broken leg femur.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 08-AS-20231023085742
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: SERRA MESA GUESTS HOME III, LLC
FACILITY NUMBER: 374601334
VISIT DATE: 07/09/2025
NARRATIVE
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Interviews revealed that the hospice agency provided the transportation and transported R1 to Kaiser Hospital. Interviews revealed that R1 was a fall risk, and Serra Mesa Guest Home had preventative measures to protect R1 from falling, such as a half-bed rail, bed alarms, fall mats, and low-level mattresses. Interviews revealed that facility staff were instructed to check on R1 every two hours and reposition R1. Interviews revealed R1 did not have one one-on-one care at the facility, and staff were not required to stay at their bedside through the night but did so to provide extra support and company for R1. It was alleged that the facility did not follow reporting requirements. Interviews revealed that the facility staff provided the documents showing that they reported the incident to Community Care Licensing (CCL) and that the incident report revealed the incident regarding R1.

Based on the information collected during the investigation, there is not enough evidence to support the allegation of neglect to resident resulting in serious bodily injury and facility did not follow reporting requirements; therefore, the allegation is deemed Unsubstantiated.
This report has been discussed and a copy was provided to Joy Singson, Caregiver at the conclusion of the visit.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6