374604204-11-5-2025-08-AS-LTEZ-DPV2WB-20251230164515

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604204
Report Date: 11/04/2025
Date Signed: 11/05/2025 08:16:05 AM

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
10/27/2025 and conducted by Evaluator Natasha Persaud

COMPLAINT CONTROL NUMBER: 08-AS-20251027113714

FACILITY NAME:	LA VALHALLA RESIDENTIAL CARE		FACILITY NUMBER:	374604204
ADMINISTRATOR:	DE VERA, JONATHAN		FACILITY TYPE:	740
ADDRESS:	1701 LA VALHALLA PL		TELEPHONE:	(619) 499-5853
CITY:	EL CAJON	STATE: CA	ZIP CODE:	92019
CAPACITY:	6	CENSUS: 4	DATE:	11/04/2025
		UNANNOUNCED	TIME BEGAN:	12:50 PM
MET WITH:	Staff, Rowena Ramos		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff neglect, resulting in pressure injuries
Staff did not treat resident with dignity
Staff did not meet resident's incontinent needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced visit to commence a complaint investigation. LPA identified herself and was allowed entry into the facility by Staff, Rowena Ramos. Administrator, Jonathan de Vera arrived during the visit.

During the investigation, LPA briefly toured the facility, reviewed records, and interviewed staff and residents. It was alleged that staff neglect resulted in a pressure injury and staff did not meet resident's incontinent needs. It was reported Resident #1 (R1) sustained pressure injuries at the facility. The facility staff indicated R1 had a heat rash, not pressure injuries. R1 confirmed they had heat rash under their breast, between their inner thighs and on their buttocks area. R1 was unable to distinguish the difference between a pressure injury and a rash. LPA observed the areas on R1, which appeared reddened and flaky. R1 explained the facility staff were applying ointment and addressing the rash, as well as their home health agency. On 10/24/25, R1 was transported to hospital due to their catheter leaking. On 10/29/25, LPA spoke with a hospital staff member and verified that R1 did not have any identified or documented pressure injuries. Continued on LIC 9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2025

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-20251027113714

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 VALHALLA RESIDENTIAL CARE	FACILITY NUMBER: 374604204
	VISIT DATE: 11/04/2025

NARRATIVE

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R1 confirmed they went to the hospital multiple times due to their catheter leaking, which needed to be replaced. R1 also stated once the catheter was replaced there were other issues with their catheter, and they had to return 3 days in a row to the hospital for catheter assistance. R1 wore briefs in addition to the use of the catheter. R1 confirmed their briefs were being changed by staff and their urine bag was emptied. R1 stated their incontinent care needs were met by the facility staff. Facility staff interviews confirmed they applied ointment provided by R1’s nurse, changed R1’s briefs and emptied R1’s urine bag. Staff also explained that due to the catheter leaking, the urine would leak into R1’s diaper. However, staff changed R1’s briefs on regular basis. Staff also stated they changed R1’s briefs, 15 times in one day, to ensure R1 stayed dry due to the leakage from the catheter.

It was also alleged that staff did not treat a resident with dignity. It was reported staff were mean to R1, called resident names and told R1 they won’t help R1 anymore. R1 denied the allegation and stated staff treated them well and were very attentive to R1’s needs. Staff explained one day R1 returned to the facility from the hospital. That day, R1 needed a brief change upon return. However, staff told R1 to wait, as the other caregiver was about to arrive at the facility to assist. R1 required a 2-person assist for safety reasons. Staff stated the facility has a Hoyer lift but R1 refused to use it. Therefore, the other staff were needed.

During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegations. The allegations are deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Staff, Rowena Ramos whose signature below confirms receipt of these rights.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2025

LIC9099 (FAS) - (06/04)

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