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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603713
Report Date: 02/21/2026
Date Signed: 02/27/2026 01:29:38 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
02/07/2025 and conducted by Evaluator Janet Ngallo
COMPLAINT CONTROL NUMBER: 08-AS-20250207145638
FACILITY NAME:PARKVIEW MEMORY CARE AT PARADISE VILLAGEFACILITY NUMBER:
374603713
ADMINISTRATOR:AGUILAR, GEOVANNIFACILITY TYPE:
740
ADDRESS:735 ARCADIA AVENUETELEPHONE:
(619) 475-5040
CITY:NATIONAL CITYSTATE: CAZIP CODE:
91950
CAPACITY:70CENSUS: 52DATE:
02/21/2026
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Resident Care Coordinator Patricia PestanoTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Neglect/Lack of Supervision resulted in serious injury.
INVESTIGATION FINDINGS:
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On 02/21/2026, LPA Janet Ngallo conducted a subsequesnt visit to deliver findings regarding the above-mentioned allegation. LPA spoke with Resident Care Coordinator Patricia Pestano and explained the purpose of the visit.

Regarding the allegation of Neglect/Lack of Supervision resulted in serious injury, resident (R1) had several falls in the facility causing R1 to have hip fractures.

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

Facility staff reported they initiated more supervision when able and frequent status checks every hour because R1 was considered to be a fall risk. S1 & S2 completed numerous assessments to determine an accurate service and care plan for R1 and to increase assistance with services and care.

(Cont. on LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Janet Ngallo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2026
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-20250207145638
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: PARKVIEW MEMORY CARE AT PARADISE VILLAGE
FACILITY NUMBER: 374603713
VISIT DATE: 02/21/2026
NARRATIVE
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(Cont. from LIC 9099)

R1 was sent to the hospital several times due to the falls, and during the falls had sustained a left hip fracture 6/11/2024 and a right hip fracture 08/2024 while residing in assisted living. S2 said they completed multiple assessments and recommended additional supervision for R1. Staff reported that additional status checks were implemented and R1s medications were changed by physician to assist R1 with sleep and anxiety. Facility staff notified family during any change of condition or when an incident occurred. The incident was documented, and timely medical care was provided.

R1 had nine falls while residing in assisted living and three falls within one month of residing in memory care. On 09/05/24, the facility had a care conference with the family recommending a personal caregiver and a higher level of care for R1. R1 had six additional falls after the care conference.

At the time of the complaint visit, Resident Care Coordinator Patricia Pestano was informed that the incident is currently under review and a future civil penalty may apply based on Health and Safety Code ยง 1569.49.

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. An Immediate Civil Penalty of $500.00 was also assessed/charged (refer to the LIC421-IM page). An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Resident Care Coordinator Patricia Pestano, whose signature below confirms receipt of these rights.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Janet Ngallo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 08-AS-20250207145638
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: PARKVIEW MEMORY CARE AT PARADISE VILLAGE
FACILITY NUMBER: 374603713
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/22/2026
Section Cited
CCR
87411(a)
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(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...of the facility require such additional staff for the provision of adequate services.
This was not met as evidenced by:
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Staff will provide proof of scheduled training with management staff within 24 hours to LPA via email. Training will be completed and submitted to LPA with sign-in sheet and training topic clearly noted via email by 02/25/2026.
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Based on interviews and records review, Licensee failed to provide increased supervision to R1 and cause R1 to have multiple falls which poses an immediate Health, Safety, or Personal Rights 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: Lizzette Tellez
LICENSING EVALUATOR NAME: Janet Ngallo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2026
LIC9099 (FAS) - (06/04)
Page: 3 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
02/07/2025 and conducted by Evaluator Janet Ngallo
COMPLAINT CONTROL NUMBER: 08-AS-20250207145638

FACILITY NAME:PARKVIEW MEMORY CARE AT PARADISE VILLAGEFACILITY NUMBER:
374603713
ADMINISTRATOR:AGUILAR, GEOVANNIFACILITY TYPE:
740
ADDRESS:735 ARCADIA AVENUETELEPHONE:
(619) 475-5040
CITY:NATIONAL CITYSTATE: CAZIP CODE:
91950
CAPACITY:70CENSUS: DATE:
02/21/2026
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:TIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Neglect/Lack of Supervision resulted in residnet on resident altercation.
Insufficient Staff.
Staff lack training.
INVESTIGATION FINDINGS:
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Regarding the allegation of Neglect/Lack of Supervision resulted in resident on resident altercation, a resident was accidentally in R1s and allegedly slapped R1 in R1s sleep.

S1 stated that resident entered R1s room and slapped R1 per what the resident reported. S1 said there were no witnesses, staff communicated with family about the incident.

According to the incident report, the door to the R1s room was left unlocked when a staff observed another resident in the room and escorted the other resident out. No injuries were noted at the time of the incident. R1 claims that the resident who entered R1s room hit R1 in the face while R1 was asleep and lying in bed. R1 did not report any pain at the time.

(Cont. on LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Janet Ngallo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 08-AS-20250207145638
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: PARKVIEW MEMORY CARE AT PARADISE VILLAGE
FACILITY NUMBER: 374603713
VISIT DATE: 02/21/2026
NARRATIVE
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(Cont. from LIC 9099)

For the allegation of Insufficient Staff, RP alleged that facility appeared to be understaffed.

Facility schedule shows that on certain days the ratio for care staff and residents will be 1:7 or 1:8. Night shift has three staff scheduled which starts at 10:00 pm.

For the allegation of Staff lack training, RP stated that some of the night shift caregivers were not qualified to meet the needs of residents.

According to records review, all staff go through the required initial and annual training all through their tenure in the facility.

Based on interviews and records review, the department has determined that although the allegations 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 allegation is UNSUBSTANTIATED. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to ______, whose signature below confirms receipt of these rights.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Janet Ngallo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5