374603625-11-10-2025-08-AS-SJAB-DNDNXK-20251113095116

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603625
Report Date: 11/10/2025
Date Signed: 11/10/2025 05:10:42 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
10/22/2025 and conducted by Evaluator Amy Rodgers

COMPLAINT CONTROL NUMBER: 08-AS-20251022081308

FACILITY NAME:	STELLAR CARE		FACILITY NUMBER:	374603625
ADMINISTRATOR:	BRANDON CHO		FACILITY TYPE:	740
ADDRESS:	4518 54TH STREET		TELEPHONE:	(619) 287-2920
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92115
CAPACITY:	150	CENSUS: 104	DATE:	11/10/2025
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Executive Director Brandon Cho		TIME COMPLETED:	04:50 PM

ALLEGATION(S):

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Staff do not follow doctor's orders
Staff do not ensure resident is receiving medication as prescribed
Staff did not ensure resident's representative was notified of resident's change in condition in a timely manner

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Brandon Cho

The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, and outside sources, as well as a review of resident records, including physician’s orders, Medication Administration Records (MARs), progress notes, and care plans.

Resident #1 (R1) is an 84-year-old resident admitted to the facility on November 9, 2019, with diagnoses including Alzheimer’s Disease, depression, insomnia, and diabetes. R1 is non-ambulatory, visually impaired, and requires assistance with all activities of daily living, including medication and insulin administration. She is at high risk for falls and receives night supervision due to confusion and wandering. R1 is unable to self-administer medications and requires ongoing observation due to cognitive impairment. (Continued on LIC9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:	DATE: 11/10/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20251022081308

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: STELLAR CARE	FACILITY NUMBER: 374603625
	VISIT DATE: 11/10/2025

NARRATIVE

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(Continued form LIC9099)
On October 22, 2025 it was reported to Community Care Licensing(CCLD) that staff do not follow doctor’s orders. More specifically, the reporting party (RP) alleged that on October 14, 2025, staff attempted to administer insulin to R1 at 7:00 AM, prior to the resident eating, which the RP believed was inconsistent with the physician’s orders. Staff interviews confirmed that on 10/14/25, a med-tech checked R1’s blood sugar around 7:00 AM but did not administer insulin. A second staff member, who was present at the time, clarified that insulin is only administered as per physicians' orders. Records review confirmed that insulin was not administered during the 10/14/25 incident and that staff reviewed insulin timing procedures afterward. LPA observations confirmed that insulin administration protocols were posted and understood by staff.

It was further alleged staff do not ensure resident is receiving medication as prescribed. More specifically, that during the resident’s COVID isolation period (August 4–5, 2025), staff failed to monitor the resident adequately, resulting in a low blood sugar episode. Staff interviews confirmed that insulin and glucose monitoring were provided to R1 during that time. Resident interviews did not indicate missed medications. Records review of the MAR showed consistent documentation of insulin administration and blood glucose monitoring. Progress notes from August 2025 documented a hypoglycemic event that was treated appropriately and reported to the POA. LPA observations confirmed that medication storage and documentation practices were in place.

It was further alleged staff did not ensure resident’s representative was notified of a change in condition in a timely manner. More specifically, RP stated that on October 18, 2025, the resident was reportedly unresponsive with a high blood sugar reading, and the RP was not notified until several hours later via email.Staff interviews confirm that all POA's are notified per CCLD regulations. Reporting party confirmed that they received an email at 3:00 PM regarding an incident that occurred around 11:30 AM. Records review confirmed the incident and the email communication but did not include documentation of a phone call or earlier notification. There was no evidence of harm or a pattern of delayed notification.

Based on interviews, direct LPA observations, and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred. Therefore, the allegation is UNSUBSTANTIATED
An exit interview was conducted with Executive Director Cho, to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:	DATE: 11/10/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2025

LIC9099 (FAS) - (06/04)

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