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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604267
Report Date: 05/30/2025
Date Signed: 05/30/2025 05:56:33 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
11/14/2022 and conducted by Evaluator Marisela Garcia-Centeno
COMPLAINT CONTROL NUMBER: 08-AS-20221114144958
FACILITY NAME:CLOISTERS OF THE VALLEY, LLCFACILITY NUMBER:
374604267
ADMINISTRATOR:DELABARRE, EMILYFACILITY TYPE:
740
ADDRESS:4171 CAMINO DEL RIO SOUTHTELEPHONE:
(619) 283-2226
CITY:SAN DIEGOSTATE: CAZIP CODE:
92108
CAPACITY:70CENSUS: 65DATE:
05/30/2025
UNANNOUNCEDTIME BEGAN:
02:30 AM
MET WITH:Executive Director Tia Suuronen-GoodwinTIME COMPLETED:
04:25 PM
ALLEGATION(S):
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Facility staff did not address slipping hazard, resulting in resident falling and sustaining a fracture
Facility staff did not seek timely medical care for resident
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 Executive Director Tia Suuronen-Goodwin, to whom she identified herself and explained the purpose of the visit.

The Department investigated the complaint allegations through a facility inspection, observations, multiple interviews with staff and external sources, and a thorough review of relevant records.

On November 14, 2022, Community Care Licensing (CCL) received a complaint alleging that staff failed to address slipping hazards, resulting in resident R1 sustaining a serious injury—a lumbar vertebral (L1) compression fracture. A confidential list (LIC 811) was provided to staff to identify R1.

(Continue at LIC9099)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
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 6
Control Number 08-AS-20221114144958
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: CLOISTERS OF THE VALLEY, LLC
FACILITY NUMBER: 374604267
VISIT DATE: 05/30/2025
NARRATIVE
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(Continue from LIC9099)

The complaint specifically alleged that R1 experienced an unwitnessed fall in their room on the night of November 8, 2022. R1’s medical and facility records indicated a diagnosis of unspecified dementia and residence in the facility’s memory care section. According to a physician’s report dated January 19, 2022, R1 was ambulatory and able to communicate needs.

Interviews with R1 and outside sources consistently reported that R1 slipped due to water on the floor. After the fall, R1 did not report the incident to staff and was able to get up from the floor unassisted and return to bed. The next morning, R1 complained to the staff of lower back pain and requested pain medication. Staff interviews revealed that R1 denied any fall or injury.

Interviews with residents, staff, and outside sources confirmed that several rooms, including R1’s, had ceiling leaks for several days due to broken water pipes. Maintenance had placed buckets and towels under leaks to mitigate hazards. Although staff had placed buckets and towels as a temporary measure, it failed to adequately address the hazard. During interviews, it was confirmed that the wet floor condition contributed to R1’s fall. During a visit conducted on November 21, 2022, the ceiling repairs caused by the water leak in R1’s and other residents’ rooms were confirmed by observation. Additional interviews with staff and residents did not yield any other reported injuries caused by the water leaks.

It was also alleged that facility staff did not seek timely medical care for R1 to meet their needs. On November 9, due to persistent back pain, the staff ordered a mobile x-ray, which returned unclear results. Despite ongoing back pain complaints, additional medical evaluation was not pursued until November 11, when R1 disclosed the fall to their responsible party. R1 was then immediately transported by R1’s responsible party to the hospital, where a CT scan confirmed an acute L1 vertebral fracture. R1 was subsequently discharged to a skilled nursing facility for rehabilitation. It was confirmed that R1 recovered and was discharged back to the facility from skilled nursing.

Although staff did not receive timely notification of the fall, R1 complained of back pain, and medical attention was delayed until November 11, when a hospital CT scan confirmed the injury. The delay in seeking further medical evaluation despite ongoing pain was deemed inadequate care.
(continue at LIC9099C)
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 08-AS-20221114144958
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: CLOISTERS OF THE VALLEY, LLC
FACILITY NUMBER: 374604267
VISIT DATE: 05/30/2025
NARRATIVE
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(Continue from LIC9099C)

Based on interviews and records review, sufficient evidence supports the allegation that staff negligence in addressing the slipping hazard directly resulted in R1’s fall and injury.
It was also substantiated that facility staff did not seek timely medical care for R1. Although the initial x-ray was unclear, staff should have pursued further evaluation when R1 continued to report acute pain. Timely medical attention is a reasonable expectation to ensure residents' health and safety, especially those with dementia.

The Department finds the allegations substantiated, meeting the preponderance of evidence standard was met. Deficiencies were cited under Title 22, Division 6, Chapter 8 of the California Code of Regulations, detailed on LIC 9099-D. An immediate $500 civil penalty was assessed, and a plan of correction was jointly formulated with Executive Director Suuronen-Goodwin. Per Health and Safety Code Section 1569.49, an additional civil penalty is under review by the Program Administrator of the Community Care Licensing Division.

An exit interview was conducted with Executive Director Suuronen-Goodwin, who was provided a copy of this report, the Confidential Names List (LIC 811), LIC 9099D Deficiency Report, and the Licensee Appeal Rights (9058 03/22).
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 08-AS-20221114144958
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: CLOISTERS OF THE VALLEY, LLC
FACILITY NUMBER: 374604267
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
06/30/2025
Section Cited
CCR
87303
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87303(a) Maintenance and Operation The facility shall be clean, safe, ......afety and well-being of residents, employees and visitors. The licensee did not ensure the floors of residents’ rooms were free from slip hazards to ensure the health and safety of the residents while in care. This requirement was not met as evidenced by:
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Licensee agreed to provide training by a third party provider to staff in the maintenance and operation of the facility to ensure the health and safety of the residents in care.
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Based on observations, records review, and interviews the licensee did not address slipping hazard, to ensure the health and safety of the residents resulting in a resident (R1) falling and sustaining a fracture. This posed an immediate health and safety risk to one (1) of (59) residents in care.
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Licensee will submit documentation of training conducted by POC due date of 6/30/2025.
Deficiency Dismissed
Type A
06/30/2025
Section Cited
CCR
887466
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887466 Observation of the Resident
The licensee shall ensure that residents are regularly observed ... such observation reveals unmet needs. ...resident's physician ..... Licensee did not seek timely medical attention when a change in condition was observed. This requirement was not met as evidenced by:
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Licensee agreed to provide training to staff by a third party provider on the regulations required to conduct observations to monitor changes in conditions of residents and care to ensure timely medical attention to meet residents' needs. Licensee agreed to submit documentation of the training conducted by POC due date 6/30/2025.
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Based on observations, records review, and interviews with staff and outside sources, the licensee did not seek timely medical care for resident (R1) when a change in condition was observed. This posed an immediate health and safety risk for one (1) of (59) residents in care.
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Licensee agreed to submit documentation of the training conducted by POC due date 6/30/2025.
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: Jennifer Lott
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
11/14/2022 and conducted by Evaluator Marisela Garcia-Centeno
COMPLAINT CONTROL NUMBER: 08-AS-20221114144958

FACILITY NAME:CLOISTERS OF THE VALLEY, LLCFACILITY NUMBER:
374604267
ADMINISTRATOR:DELABARRE, EMILYFACILITY TYPE:
740
ADDRESS:4171 CAMINO DEL RIO SOUTHTELEPHONE:
(619) 283-2226
CITY:SAN DIEGOSTATE: CAZIP CODE:
92108
CAPACITY:70CENSUS: 61DATE:
05/30/2025
UNANNOUNCEDTIME BEGAN:
02:30 AM
MET WITH:Executive Director Tia Suuronen-GoodwinTIME COMPLETED:
04:25 PM
ALLEGATION(S):
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Facility staff did not maintain the facility at a comfortable temperature for residents
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 Executive Director Tia Suuronen-Goodwin, to whom she identified herself and explained the purpose of the visit.

The Department investigated the complaint allegation described above. The investigation included a facility inspection, observations, and multiple interviews with staff and residents.

On November 14, 2022, Community Care Licensing (CCL) received a complaint alleging that staff failed to maintain a comfortable temperature for residents. Specifically, it was alleged that during a visit earlier in November, some rooms were too cold because the heater was not functioning.

(Continue at LIC9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 08-AS-20221114144958
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: CLOISTERS OF THE VALLEY, LLC
FACILITY NUMBER: 374604267
VISIT DATE: 05/30/2025
NARRATIVE
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(continue from LIC9099A)

During a follow-up inspection on November 21, 2022, facility temperatures were measured and found to be within the range required by Title 22 regulations, between 74-75 degrees Fahrenheit. Multiple interviews with residents and staff confirmed that the heater had been nonfunctional for four days in November. However, interviewees consistently reported that the facility’s temperature remained comfortable, and no concerns were raised about rooms being too cold. One resident recalled the heater outage but stated that wearing sweaters and using blankets provided sufficient comfort.

Staff and residents also reported receiving no formal complaints regarding the facility’s temperature.

Based on the investigation’s findings—including observations and interviews with key staff and residents—there was insufficient evidence to substantiate the allegation.
Therefore, this allegation is unsubstantiated. An unsubstantiated finding means that although the alleged violation may have occurred, there is not a preponderance of evidence to confirm it.

An exit interview was conducted with Executive Director Tia Suuronen-Goodwin at the conclusion of the visit. She was provided with a copy of this report and the Licensee Appeal Rights (9058 03/22).
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6