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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604063
Report Date: 08/18/2025
Date Signed: 12/02/2025 08:59:59 AM

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
05/17/2024 and conducted by Evaluator Amy Domingo
COMPLAINT CONTROL NUMBER: 08-AS-20240517083953
FACILITY NAME:MESAVIEW SENIOR ASSISTED LIVINGFACILITY NUMBER:
374604063
ADMINISTRATOR:GENOVEVA GUERREROFACILITY TYPE:
740
ADDRESS:7971 CULOWEE STREETTELEPHONE:
(619) 466-0253
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY:30CENSUS: 30DATE:
08/18/2025
UNANNOUNCEDTIME BEGAN:
10:52 AM
MET WITH:Ileana Castro Assistant ManagerTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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The resident developed a pressure injury while in care.
Staff did not seek medical attention for the resident in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced herself and disclosed the purpose of the visit to the Assistant Manager, Ileana Castro.

The Department’s investigation consisted of a review of facility and outside records, as well as interviews with staff, residents, and outside sources. On May 17, 2024, it was alleged that a resident developed a pressure injury while in care, and staff did not seek medical attention for the resident in a timely manner.

Resident 1 (R1) was diagnosed with COVID-19 on May 6, 2024. R1 was quarantined to their room and spent most of their time recovering. On May 11, 2024, a pressure injury was discovered on R1’s right ankle during a shower. The pressure injury was reported to Staff 1 (S1), who called R1’s Primary Care

(This is an amended report from 8/18/25, the correction is on the third page of the LIC9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025
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 4
Control Number 08-AS-20240517083953
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: MESAVIEW SENIOR ASSISTED LIVING
FACILITY NUMBER: 374604063
VISIT DATE: 08/18/2025
NARRATIVE
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(Continued from LIC9099 2 of 3)
physician. The front desk for the office was closed due to it being a Saturday, and according to S1, they left a message for the Physician requesting a return call to discuss R1’s pressure injury.

Three different staff members observed R1’s pressure injury, and they all provided different descriptions of it. Although a body check form is required when a pressure injury is discovered on a resident, there was not one done.

Staff 2 (S2) said they checked R1’s pressure injury on May 12, 2024, and May 13, 2024, and stated the pressure injury had not improved or worsened, there was no documentation, or information provided by other staff that R1’s pressure injury was monitored. In addition, no one from Mesaview called the Physician’s office on Monday, May 13, 2024, to follow up about R1’s pressure injury. R1 was transported from the facility to the medical office on May 14, 2024, for a follow-up appointment referencing their May 6, 2024, COVID-19 diagnoses. During the visit, the medical office staff discovered R1’s right ankle pressure injury, and the sock they were wearing was stuck to their skin due to the fluid oozing from the pressure injury.

R1 was evaluated by the medical office’s staff, who diagnosed R1’s pressure injury as an unstageable pressure injury due to the injury being covered with slough and being unable to see the depth of the wound. R1 was transported to the Hospital where they were admitted and administered antibiotics to treat their pressure injury.

On May 17, 2024, it was alleged that a resident developed a pressure injury, and staff did not seek medical attention for the resident in a timely manner. S2 was interviewed and stated they discovered R1’s pressure injury on May 11, 2024, in the early morning while changing R1. S2 described the pressure injury as being a circle about the size of a quarter, with redness and an outer red ring around the pressure injury. S2 stated on May 11, 2024, that they reported R1’s pressure injury to the medical office by leaving a message. On Monday, May 13, 2024, Mesaview staff did not receive a call from the medical office related to R1’s pressure injury, and no one from Mesaview called the office to follow up about R1’s pressure injury.

Staff 4 (S4) was interviewed, and they stated they discovered R1’s pressure injury on May 12, 2024, while changing R1. S4 described R1’s pressure injury as a “boil, a little red and a little wet.” During an interview with OS1, they stated that R1’s sock was stuck to their skin due to the fluid oozing from the pressure injury. OS1, as well as two physicians at the medical office, diagnosed the pressure injury as an unstageable pressure injury.

(Continued on LIC9099)

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 08-AS-20240517083953
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: MESAVIEW SENIOR ASSISTED LIVING
FACILITY NUMBER: 374604063
VISIT DATE: 08/18/2025
NARRATIVE
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(Continued from LIC9099 3 of 3)

OS1 said the wound was diagnosed as unstageable due to it being covered with slough and their inability to see how deep the wound was. OS1 had R1 transferred to the Hospital to be further evaluation and treatment.

Staff 4 (S4) was interviewed, and they stated they discovered R1’s pressure injury on May 12, 2024, while changing R1. S4 described R1’s pressure injury as a “boil, a little red and a little wet.”



During an interview with OS1, they stated that R1’s sock was stuck to their skin due to the fluid oozing from the pressure injury. OS1, as well as two physicians at the medical office, diagnosed the pressure injury as an unstageable pressure injury. OS1 said the wound was diagnosed as unstageable due to it being covered with slough and their inability to see how deep the wound was. OS1 had R1 transferred to the Hospital to be further evaluation and treatment.

OS1 said the first stage of the pressure injury would have been redness, which should have been immediately reported. The staff should have monitored the area closely and rotated the patient to prevent the pressure injury from worsening. By the time R1 was examined at the medical office on May 14, 2024, their pressure injury was open, oozing, and stuck to their sock from the fluid covering the pressure injury. Although S1 stated they checked R1’s pressure injury on May 12, 2024, and May 13, 2024, and stated the pressure injury had not improved or worsened, there was no documentation or information provided by other staff that R1’s pressure injury was monitored.

OS1 said they found no record of Mesaview staff calling the medical office on May 11, 2024, or any other time to report R1’s pressure injury. OS1 confirmed the clinic’s front office is closed during the weekend; however, Mesaview is also provided with a 24-hour emergency number for these calls so the staff can respond to them immediately.

The Department investigated the above allegations, and the preponderance of the evidence standard was met. Therefore, the above allegations are substantiated.

Pursuant to the California Code of Regulations, Title 22, Division 6 deficiencies were cited on the attached 9099-D. An immediate civil penalty of $1000 was assessed during today's visit for the facility's neglect.lack of care and supervision resulting in a resident's pressure injury and hospitalization. At this time, per Health and Safety Code Section 1569.2(c), an additional civil penalty assessment is under review by the Program Administrator of the Community Care Licensing Division.

An exit interview was conducted with the Assistant Manager, Ileana Castro, and a plan of correction was jointly developed. A copy of these reports, along with Licensee/Appeal Rights (LIC 9058 03/22), was provided after the visit.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 08-AS-20240517083953
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: MESAVIEW SENIOR ASSISTED LIVING
FACILITY NUMBER: 374604063
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/18/2025
Section Cited
CCR
87466
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Observation of the Resident, staff must observe residents for changes in condition and respond appropriately. (The licensee shall ensure that residents are regularly observed for changes in physical,mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any)

This requirement was not met, as evidenced by:
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The plan of correction was cleared on today’s date. The facility also conducted an in-service on skin care, pressure ulcers, and reporting. The facility has implemented a new skin assessment sheet to address the deficiency and has provided the LPA with the documentation.
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Based on records review and interviews, the licensee did not observe the resident for changes in 1 out of 30 residents. This posed an immediate health and safety risk to persons in care.
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Type A
08/18/2025
Section Cited
CCR
87465(g)
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Incidental Medical Care -The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health..

This requirement was not met, as evidenced by:
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The plan of correction was cleared on today’s date. The facility also conducted an in-service on skin care, pressure ulcers, and reporting. The facility has implemented a new skin assessment sheet to address the deficiency and has provided the LPA with the documentation.
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Based on records review and interviews, the licensee did not accord incidental medical care to 1 out of 30 residents. This posed an immediate health and safety 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: Amy Domingo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4