374604267-1-26-2026-08-AS-LTEZ-DR6V4U-20260210150655

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604267
Report Date: 01/26/2026
Date Signed: 01/26/2026 02:24:43 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
02/04/2025 and conducted by Evaluator Janet Ngallo

COMPLAINT CONTROL NUMBER: 08-AS-20250204132812

FACILITY NAME:	CLOISTERS OF THE VALLEY, LLC		FACILITY NUMBER:	374604267
ADMINISTRATOR:	DISHA FRANCES-HALL		FACILITY TYPE:	740
ADDRESS:	4171 CAMINO DEL RIO SOUTH		TELEPHONE:	(619) 283-2226
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92108
CAPACITY:	70	CENSUS: 62	DATE:	01/26/2026
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Executive Director Tia Suuronen-Goodwin		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Neglect resulting in delayed medical care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Janet Ngallo conducted an unannounced visit to deliver findings in the above complaint allegation. LPA identified self and discussed the purpose of the visit with Executive Director Tia Suuronen-Goodwin.

On February 4, 2025, Community Care Licensing (CCL) received a complaint alleging facility staff did not provide medical care to Resident 1 (R1) after it was found that R1 had signs and symptoms of an illness. The Department conducted internal and external interviews and reviewed multiple facility records as well as outside source medical records. According to R1’s Physician Report dated January 12, 2024, R1 is confused and disoriented, requires continuous bed care and is bedridden. R1’s Appraisal, R1 requires maximum assistance with transfers and is frail.

(Cont. on LIC 9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Janet Ngallo
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2026

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 3

Control Number 08-AS-20250204132812

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: 01/26/2026

NARRATIVE

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(Cont. from LIC 9099)

During the investigation the Department established the following sequence of events. On January 25, 2025, facility staff reported to family and responsible parties, the facility was having an Influenza A outbreak within its staff and residents. According to an outside source interview, on January 26, 2025, R1 was noticed to have a cough, and such was reported to Staff 1 (S1). Interview with S1 revealed that R1’s Primary Care Provider (PCP) was faxed with details of the symptoms and S1 was later contacted by the PCP via telephone stating that they were unable to provide care to R1 and to contact another provider. Records and interviews collected revealed that on January 27, 2025, an outside sourced medical provider (OS1) visited R1 for other services and noted that R1 was having a cough, OS1 proceeded to report such to S1, S1 informed OS1 that this had already been reported to the medical provider. On January 28, 2025, R1’s responsible party contacted the facility and was informed R1 had not received medical care for symptoms. Responsible party proceeded to contact a medical provider and schedule a video visit with R1 for the next morning, January 29, 2025. During the video appointment, the medical provider advised the responsible party and facility staff to contact emergency medical care immediately. Medical records collected established that after being admitted to the hospital, R1 was diagnosed with Influenza A and acute hypoxic respiratory failure. Further interviews revealed that no staff communicated with the resident, or responsible party regarding response from the first medical provider and did not provide additional medical care to R1 between January 26, 2025, until January 29, 2025, therefore medical care was delayed.

Based on interviews conducted, review of records, including outside sources records, a preponderance of evidence exists to support the allegation. Therefore, the allegation is substantiated. A deficiency is cited per the Health and Safety Code (refer to the attached LIC 9099-D).

The Department has determined this violation resulted in hospitalization to resident in care. An immediate Civil Penalty of $500.00 is charged and is noted on the LIC421IM. Currently, according to Health and Safety Code Section 1569.49, an additional civil penalty assessment is under review by the Program Administrator of Community Care Licensing Division. An exit interview was conducted with Executive Director Tia Suuronen-Goodwin, and a Plan of Correction was jointly developed. A copy of this report, LIC811, LIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058) were provided to Executive Director Tia Suuronen-Goodwin, signature on this form confirms receipt of documents.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Janet Ngallo
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2026

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20250204132812

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: 01/26/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/09/2026 Section Cited CCR 87456(a)(1)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility...(1)The licensee shall arrange.. care appropriate to the conditions and needs of residents. This requirement was not met, as evidenced by:	1 2 3 4 5 6 7	Licensee will conduct incidental medical and dental care in-service training for all care staff. Documentation of the training will include a sign-in sheet with participant names and the training topic clearly noted. Proof of completion due by 02/09/2026.
	8 9 10 11 12 13 14	Based on interviews and records review, the licensee did not provide medical care to 1 out of 63 residents in care. This posed an immediate personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 01/26/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2026

LIC9099 (FAS) - (06/04)

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