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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603431
Report Date: 02/13/2026
Date Signed: 02/13/2026 02:43:29 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
and conducted by Evaluator Marisela Garcia-Centeno
COMPLAINT CONTROL NUMBER: 08-AS-20250725155959
FACILITY NAME:ACTIVCARE AT ROLLING HILLS RANCHFACILITY NUMBER:
374603431
ADMINISTRATOR:BONGHABIH N. SHEYFACILITY TYPE:
740
ADDRESS:850 DUNCAN RANCH ROADTELEPHONE:
(619) 482-8000
CITY:CHULA VISTASTATE: CAZIP CODE:
91914
CAPACITY:80CENSUS: 53DATE:
02/13/2026
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Program Director, Karen PultorakTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Lack of supervision, resulting in multiple falls
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced visit to deliver investigative findings. Upon arrival, LPA was greeted by Program Director, Karen Pultorak, to whom LPA identified herself and explained the purpose of the visit.

Investigation Overview
Community Care Licensing (CCL) initiated an investigation in response to a complaint received on July 25, 2025, alleging that lack of supervision resulted in R1 having multiple falls resulting in serious bodily injury. Specifically, it was alleged that R1 experienced multiple falls (three (3)) that resulted in serious bodily injuries requiring hospitalization. A Confidential Names List (LIC 811) was provided to facility staff to identify R1.

(continue at LIC9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2026
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 6
Control Number 08-AS-20250725155959
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: ACTIVCARE AT ROLLING HILLS RANCH
FACILITY NUMBER: 374603431
VISIT DATE: 02/13/2026
NARRATIVE
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(Continue from LIC9099)

To investigate these allegations, the Department conducted an onsite facility inspection, reviewed facility and medical records, reviewed incident reports, and conducted interviews with facility management staff, direct care staff, and outside sources. The Department also reviewed medical provider records and hospital records covering the relevant time period. Through these investigative methods, the Department assessed the facility’s compliance with applicable laws and regulations and evaluated the care and supervision provided to R1.

According to the complaint, staff failed to provide adequate supervision to R1, resulting in repeated falls, including a bathroom fall involving spilled mouthwash and a courtyard fall where R1 was found outside without staff present. It was further alleged that R1 sustained serious injuries including a cervical fracture and head injuries requiring emergency medical evaluation and treatment.

Resident Background
A review of R1’s facility and medical records showed R1 was admitted to the facility in 2021 and had diagnoses including dementia with cognitive impairment and unsteady gait. Records documented fall risk, wandering behavior, and need for assistance with activities of daily living, including bathing, dressing, toileting, and transfers.
Medical assessments and physician records documented that R1 had an unsteady gait and was considered a fall risk. Records showed R1 sustained a cervical spine fracture in April 2025 and thereafter required use of a cervical collar and ongoing fall precautions. Physician follow-up notes repeatedly documented fall risk, neck injury, and continued need for monitoring and protective interventions.
Facility Needs and Services Plans reviewed during the investigation documented that R1 was a high fall risk, required supervision, and that staff were to monitor R1 for changes in gait and balance, ensure use of assistive devices and cervical collar, supervise due to wandering behavior, and be aware of R1’s whereabouts at all times.


(Continue at LIC9099C)
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 08-AS-20250725155959
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: ACTIVCARE AT ROLLING HILLS RANCH
FACILITY NUMBER: 374603431
VISIT DATE: 02/13/2026
NARRATIVE
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(Continue from LIC9099C)

Investigative Findings
The Department reviewed facility records including resident assessments, Needs and Services Plans, incident reports, staffing information, and medical and hospital records. Records and interviews confirmed that R1 experienced three separate falls within approximately a three-month period resulting in injuries and hospital evaluations.

First Fall — April 23, 2025 (Bathroom Incident):
Facility incident reports and management interviews documented that R1 was being assisted by a caregiver in the bathroom with brushing teeth. Mouthwash was provided, the container was knocked from the caregiver’s hand, liquid spilled on the floor, and R1 stepped backward, slipped, and fell onto a walker. R1 sustained a laceration and neck injury and was transported to the hospital. Hospital records confirmed a cervical spine (C2) fracture. After returning to the facility, R1 was placed in a cervical collar and identified as high fall risk. The Needs and Services Plan was updated to include increased monitoring and fall precautions.

Second Fall — June 8, 2025 (Bedroom Incident):
Facility incident reports and medical records documented that during overnight rounds R1 was found on the floor next to the bed by staff. A medication technician assessed R1 and noted a head injury. R1 was transported to the hospital. Hospital and physician records documented head injury findings and continued cervical spine concerns, with continued cervical collar orders and fall precautions.

Third Fall — July 19, 2025 (Courtyard Incident):
Facility incident reports, staff interviews, and nursing interview confirmed that R1 was found on the ground in the courtyard with a walker overturned nearby. The fall was unwitnessed. Staff assessment documented a bump to the back of the head and R1 was transported to the hospital for evaluation. Hospital records confirmed emergency evaluation following an unwitnessed fall. Staff interviews confirmed that caregivers were not consistently present outside with residents and that residents were at times in the courtyard without direct staff supervision.

(Continue at LIC9099C)
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 08-AS-20250725155959
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: ACTIVCARE AT ROLLING HILLS RANCH
FACILITY NUMBER: 374603431
VISIT DATE: 02/13/2026
NARRATIVE
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(Continue from LIC9099C)

Staff and Management Interviews:
Management staff acknowledged the three falls and confirmed that R1 was identified as high fall risk after the first serious injury. Management reported that care plans were updated and increased monitoring was expected. However, staff interviews showed inconsistent recall regarding who was assigned to supervise R1 at the time of the courtyard fall. At least one staff member reported discovering R1 already on the ground outside without knowing how long R1 had been there. Nursing staff stated that caregivers are not always outside with residents due to other assigned duties inside the unit.

Medical Records:
Hospital and physician records confirmed repeated fall-related evaluations, cervical spine fracture, head injuries, continued cervical collar use, and repeated physician orders for fall precautions and supervision. Outside provider notes repeatedly referenced fall risk and the need for continued monitoring.
R1’s Needs and Services Plans required supervision, wandering monitoring, fall precautions, and staff awareness of R1’s whereabouts at all times. Despite these written interventions, records and interviews confirmed that R1 was found alone after at least one unwitnessed outdoor fall and experienced repeated falls after being designated high fall risk.

Conclusion
Based on the evidence obtained through interviews, record reviews, and medical documentation, the Department determined there is sufficient evidence to substantiate the allegation that a lack of supervision resulted in R1 experiencing multiple falls resulting in serious bodily injury. Review of records disclosed that R1 was assessed as a high fall risk and required supervision and monitoring; however, supervision was not consistently provided. R1 sustained a cervical fracture and additional head injuries following unwitnessed or insufficiently supervised incidents.



Continue at LIC9099C)
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 08-AS-20250725155959
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: ACTIVCARE AT ROLLING HILLS RANCH
FACILITY NUMBER: 374603431
VISIT DATE: 02/13/2026
NARRATIVE
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(Continue from LIC9099C)

The Department finds the allegation substantiated, meeting the preponderance-of-the-evidence standard. A deficiency was cited under Title 22, Division 6, Chapter 8 of the California Code of Regulations and is detailed on LIC 9099-D. A Plan of Correction (POC) was developed with Program Director, Karen Pultorak. An immediate civil penalty of $500 was assessed today. In accordance with Health and Safety Code Section 1569.49, an additional civil penalty is under review by the Community Care Licensing Division.

An exit interview was conducted with Program Director, Karen Pultorak who was provided a copy of this report, the LIC 9099-D Deficiency Report, the LIC 811 Confidential Names List, LIC411, and the LIC 9058 Licensee Appeal Rights.
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Citations on this Visit Report are Under Appeal!

Control Number 08-AS-20250725155959
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: ACTIVCARE AT ROLLING HILLS RANCH
FACILITY NUMBER: 374603431
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
03/13/2026
Section Cited
CCR
87468.2(a)(4)
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87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:
(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by:
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The licensee agreed to conduct staff training on regulations regarding providing care and supervision to meet residents' needs. Documentation of the training will be submitted to CCL by the POC due date.
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Based on observations, records review, and interviews with staff and outside sources, licensee did not ensure that care and supervision was provided to meet R1 needs as outlined in R1’s service care plan. This posed an immediate health, safety, and personal rights risk to one 1 of 53 residents 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: Sabel Martinez
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 6