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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604267
Report Date: 02/04/2026
Date Signed: 02/04/2026 01:21:36 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
01/29/2026 and conducted by Evaluator Janet Ngallo
COMPLAINT CONTROL NUMBER: 08-AS-20260129110454
FACILITY NAME:CLOISTERS OF THE VALLEY, LLCFACILITY NUMBER:
374604267
ADMINISTRATOR:DISHA FRANCES-HALLFACILITY TYPE:
740
ADDRESS:4171 CAMINO DEL RIO SOUTHTELEPHONE:
(619) 283-2226
CITY:SAN DIEGOSTATE: CAZIP CODE:
92108
CAPACITY:70CENSUS: 63DATE:
02/04/2026
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Executive Director Tia Suuronen-GoodwinTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Staff did not provide a written incident report to resident's responsible person within seven days.
Staff did not dispense medications as prescribed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Janet Ngallo conducted an unannounced visit to initiate a complaint investigation and deliver findings regarding the above mentioned allegations. LPA identified themselves and met with Executive Director Tia Suuronen-Goodwin to discuss the purpose of the visit and elements of the complaint.

On 01/29/2026, it was alleged that staff did not provide a written incident report to resident's responsible person within seven days and that staff did not dispense medications as prescribed. The department's investigation consisted of interviews and records review.

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

DATE: 02/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2026
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-20260129110454
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: 02/04/2026
NARRATIVE
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(Cont. from LIC 9099)

Regarding the allegation that staff did not provide a written incident report to the resident's responsible person within seven days, interviews with staff corroborated the allegation. By admission, staff reported that they called Resident 1 (R1)'s responsible party the day R1's incident occurred on 01/10/2026, however they had not sent a written report within seven days. Staff reported that R1's responsible party requested the written incident report and received it on 01/29/2026.

Regarding the allegation that staff did not dispense medications as prescribed, interviews with staff corroborated the allegation. Staff #2 (S2) reported that they attempted to administer an as-needed pain medication in a method that was not consistent with the prescribed method, due to R1's condition. S2 stated that hospice staff came to the facility to demonstrate the correct administration technique for R1.

By admission, staff also reported that they administered a discontinued medication to R1 on 01/23/2026. R1's Medication Administration Record revealed that the administered medication was placed on hold on 01/23/2026. Records review of R1's discharge paperwork dated 01/22/2026, revealed a discontinuation of three (3) medications, one of which was given to R1 on 01/23/2026.

Based on interviews and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated.  California code of Regulations, Title 22, Division 6 & Chapter 8 is being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Resident Service Director Marquette Corbett, whose signature below confirms receipt of these rights.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Janet Ngallo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20260129110454
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: 02/04/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/05/2026
Section Cited
CCR
87211(a)(1)(D)
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(a) (1) A written report shall be submitted to the licensing agency..within seven days of the occurrence..(D) Any incident which threatens the welfare, safety or health.. any resident
This requirement was not met, as evidenced by:
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The Licensee will conduct in-service reporting requirements training with management staff and provide a sign-in sheet with signatures and training topic clearly noted to LPA via email by 02/05/2026

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Based on records review and interviews, licensee did not follow the facility Reporting requirements for 1 out of 63 residents. This posed a potential health and personal rights risks to persons in care.
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Type B
02/04/2026
Section Cited
CCR
87465(c)(2)
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(c)(2) If the..licensee shall be permitted to assist the resident with self-administration..requirements are met: (2)Once ordered.. medication is given according to.. directions.
This requirement was not met, as evidenced by:
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The licensee provided a sign in sheet dated 01/29/2026 and 02/02/2026 with staff signatures for in-service training for hospice services and medication administration protocols. Therefore, the POC will be cleared today, 02/04/2026.
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Based on interviews the licensee did not administer R1 with PRN medication as prescribed which posed a potential 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: Lizzette Tellez
LICENSING EVALUATOR NAME: Janet Ngallo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2026
LIC9099 (FAS) - (06/04)
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