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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374602302
Report Date: 02/24/2026
Date Signed: 02/24/2026 03:05:17 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
02/13/2025 and conducted by Evaluator Amy Rodgers
COMPLAINT CONTROL NUMBER: 08-AS-20250213153409
FACILITY NAME:LA COSTA HEIGHTS ASSISTED LIVINGFACILITY NUMBER:
374602302
ADMINISTRATOR:LINDU NAPITUPULUFACILITY TYPE:
740
ADDRESS:3111 LEVANTE STTELEPHONE:
(760) 634-2870
CITY:CARLSBADSTATE: CAZIP CODE:
92009
CAPACITY:6CENSUS: 6DATE:
02/24/2026
UNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Administrator Lindu NapitupulaTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Neglect resulting in resident developing multiple pressure injuries
INVESTIGATION FINDINGS:
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On 2/24/2026, LPA Amy Rodgers conducted a subsequent visit to deliver findings regarding the above-mentioned allegation. LPA spoke with Administrator Lindu Napitupular and explained the purpose of the visit.

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

Regarding the allegation of Neglect resulting in resident developing multiple pressure injuries, Resident (R1) sustained an open wound caused by lying on a catheter cord, staff failed to reposition R1 resulting in the development of open wound.

R1 is bedridden and requires full assistance with ADLs. R1 is provided additional care from home health. Per statements from staff and home health nurse (HH), R1 requires brief checks and repositioning every two hours to avoid pressure injuries. (Continued from LIC9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2026
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-20250213153409
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: LA COSTA HEIGHTS ASSISTED LIVING
FACILITY NUMBER: 374602302
VISIT DATE: 02/24/2026
NARRATIVE
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(Continued from LIC9099)

Caregiver (S1) cared for R1 on 2/8/2025 and 2/9/2025. On 2/8/2025, around 8:30 AM, S1 and S2 changed R1s brief. There was no wound on R1s back upper left thigh at that time. HH also visited R1 at the facility on 2/8/2025, around 10:00 AM, and did not document any new injuries. S1 said he/she checked on R1 the remainder of the shift on 2/8/2025, as well as throughout 2/9/2025. R1 did not do any brief change. S1 left at the end of the shift on 2/9/2025, around 6:30 PM and S2 took over.

On 2/10/202, around 8:00 – 9:00 AM, S2 and S3 rolled R1 to his/her side to change the brief. S2 noticed that R1s catheter cord was positioned under R1s left thigh and when S2 removed the cord, S2 observed a large open cut where the cord had been placed. S2 said he/she did not have a co-worker the evening of 2/9/2025 into the morning of 2/10/2025 therefore S2 did not reposition R1 in bed.

Based on the interviews, R1s brief was last changed on 2/8/2025, around 8:30 AM. It’s not noted when the last time S1 repositioned R1 before ending the shift on the evening of 2/9/2025, at 6:30 PM. However, S2 did not reposition R1 when S2 took over R1s care on 2/9/202, at 6:30 PM until S2 changed R1 on 2/20/2025, around 8:00 – 9:00 AM, around fourteen hours later.

Based on interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC 9099D.

The Department has determined this violation resulted in a developed of an open wound due to lack of care and supervision. An immediate Civil Penalty of $500.00 is charged and is noted on the LIC421IM. Currently, according to Health and Safety Code Section 1569.49, an additional civil penalty assessment is under review by the Program Administrator of Community Care Licensing Division.

An exit interview was conducted with Administrator Lindu Napitupula, and a Plan of Correction was jointly developed. A copy of this report, LIC 9099-D, LIC421IM and the Licensee/Appeal Rights (LIC 9058) were provided to Administrator Lindu Napitupula, signature on this form confirms receipt of documents.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2026
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
02/13/2025 and conducted by Evaluator Amy Rodgers
COMPLAINT CONTROL NUMBER: 08-AS-20250213153409

FACILITY NAME:LA COSTA HEIGHTS ASSISTED LIVINGFACILITY NUMBER:
374602302
ADMINISTRATOR:LINDU NAPITUPULUFACILITY TYPE:
740
ADDRESS:3111 LEVANTE STTELEPHONE:
(760) 634-2870
CITY:CARLSBADSTATE: CAZIP CODE:
92009
CAPACITY:6CENSUS: 6DATE:
02/24/2026
UNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Administrator Lindu NapitupulaTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Neglect resulting in resident developing sepsis
INVESTIGATION FINDINGS:
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On 2/24/2026, LPA Amy Rodgers conducted a subsequent visit to deliver findings regarding the above-mentioned allegation. LPA spoke with Administrator Lindu Napitupular and explained the purpose of the visit.

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

In addition to R1s wound discovered on 2/10/2025, facility staff noticed a change in R1s condition of shortness of breath and weakness. Facility Administrator/Staff immediately notified R1s Home Health Nurse (HH) to provide R1 immediate medical attention.

(Continued on LIC9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2026
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-20250213153409
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: LA COSTA HEIGHTS ASSISTED LIVING
FACILITY NUMBER: 374602302
VISIT DATE: 02/24/2026
NARRATIVE
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(Continued from LIC9099)

According to HH, R1 was exhibiting symptoms of a UTI the week prior to going to the hospital on 2/10/2025, and a urine sample was taken for testing. The preliminary finding of UTI was delivered to home health on 2/7/2025 and the final finding of a UTI was delivered on 2/10/2025.

HH2 added that R1 would have been prescribed antibiotics, however, R1 had been transported to the hospital before the prescription could be ordered.

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

An exit interview was conducted with Administrator Lindu Napitupular, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 08-AS-20250213153409
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: LA COSTA HEIGHTS ASSISTED LIVING
FACILITY NUMBER: 374602302
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/25/2026
Section Cited
CCR
87564(f)(1)
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87464(f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).
This was not met as evidenced by:
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The immediate threat was resolved: R1 was sent by emergency service to hospital and no longer residends at faciliy. LIcensee staff agreed to schedule basic services/ Care and Supervision training to all staff, by 3/25/2026
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Based on interviews and records review, R1 was not repositioned every two hours and developed an open wound due to lack of care and supervision which poses an immediate Health, Safety, or Personal Rights risk to persons in care.
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Training will be completed and submitted to LPA Rodgers with sign-in sheet and training topic clearly noted via email by 3/25/2026
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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: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5