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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604267
Report Date: 03/24/2026
Date Signed: 03/24/2026 12:04:05 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
12/16/2025 and conducted by Evaluator Janet Ngallo
COMPLAINT CONTROL NUMBER: 08-AS-20251216175651
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: 65DATE:
03/24/2026
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Executive Director Tia Suuronen-GoodwinTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Insufficient staff to meet the residents needs.
INVESTIGATION FINDINGS:
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Licensing Program Analyst(LPA) Janet Ngallo conducted an unannounced subsequent visit to deliver findings regarding the above-mentioned complaint allegation. LPA introduced themselves and disclosed the purpose of the visit and elements of the complaint to Executive Director Tia Suuronen-Goodwin.

On 12/16/2025, it was alleged that there was insufficient staff to meet the resident needs. 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: 03/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2026
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 5
Control Number 08-AS-20251216175651
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: 03/24/2026
NARRATIVE
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(Cont. from LIC 9099)

Interviews with staff corroborated the allegation, as staff reported the facility does not have sufficient staffing to meet resident care needs. Staff reported frequent shifts with only two caregivers responsible for more than sixty (60) residents, including multiple residents requiring two-person assistance. Staff also stated that the Resident Services Director and other non-direct care staff would frequently cover caregiver shifts due to shortages. Management acknowledged the use of external staffing agencies to compensate for staffing shortages. Resident interviews further corroborated staffing concerns, with residents reporting long wait times for assistance, delayed responses to call pendants, and challenges receiving timely incontinence care throughout their residence at the facility. Residents interviewed have resided at the facility for over three years and indicated that these delays have been an ongoing issue throughout their stay.

A facility records review of staffing schedules confirmed an average of approximately two to three caregivers per shift who were able to provide lifting or physical assistance to over sixty (60) residents.

Based on relevant interviews and records review, the preponderance of evidence has been met that the alleged violation occurred and is therefore substantiated. A deficiency is cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Executive Director Tia Suuronen-Goodwin, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Janet Ngallo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 08-AS-20251216175651
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: 03/24/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/20/2026
Section Cited
CCR
87411(a)
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(a)Facility personnel shall at all times be sufficient in numbers and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by:
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The licensee agreed to maintain staffing levels sufficient to meet resident needs and to provide in-service training on resident service care plan requirements. The facility will submit a staffing plan and documentation of the training with sign in sheet and training topic clearly noted by the POC due date.
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Based on interviews and records review, the facility did not provide sufficient staff to meet resident’s care needs. This posed a potential personal rights risk to 65 residents 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: 03/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
12/16/2025 and conducted by Evaluator Janet Ngallo
COMPLAINT CONTROL NUMBER: 08-AS-20251216175651

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: 65DATE:
03/24/2026
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Executive Director Tia Suuronen-GoodwinTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility is in financial distress.
The facility did not have sufficient hygiene items.
The facility is malodorous.
The facility did not provide residents with sufficient food.
INVESTIGATION FINDINGS:
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Licensing Program Analyst(LPA) Janet Ngallo conducted an unannounced subsequent visit to deliver findings regarding the above-mentioned complaint allegations. LPA introduced themselves and disclosed the purpose of the visit and elements of the complaint to Executive Director Tia Suuronen-Goodwin.

On 12/16/2025, it was alleged that the facility is in financial distress, the facility did not have sufficient hygiene items, the facility is malodorous, and that the facility did not provide residents with sufficient food. The department's investigation consisted of interviews, records review, and LPA observations.

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

DATE: 03/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 08-AS-20251216175651
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: 03/24/2026
NARRATIVE
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(Cont. from LIC-9099A)

Regarding the allegation that the facility is in financial distress, specifically related to maintaining hygiene supplies and sufficient food, during unannounced visits, LPA observed an adequate supply of hygiene products as well as sufficient food observed in the dining area. Resident and staff interviews consistently stated that hygiene supplies are regularly provided and accessible. Records review of food supply invoices showed ongoing and consistent purchases across all food groups. Review of invoices for incontinence and hygiene products showed consistent and sufficient purchases of hygiene and incontinence supplies.

Regarding the allegation that the facility did not provide residents with sufficient food, residents consistently reported that they receive enough food for their meals.

Regarding the allegation that the facility did not have sufficient hygiene items, interviews reported that some staff prefer using briefs over pull-up products because they find them easier to manage, however, pull-up incontinence products were available at the facility.

Regarding the allegation that the facility is malodorous, interviews with staff and residents consistently stated that they have not observed any foul or persistent odors in the facility and reported that housekeeping staff clean the facility daily. During multiple unannounced visits, LPA did not observe any malodors in the facility.

The Department has investigated the above-mentioned allegations and based upon the information obtained during this investigation, it is determined that the preponderance of evidence was not met to support or corroborate these allegations and therefore deemed unsubstantiated.

An exit interview was conducted with Executive Director Tia Suuronen-Goodwin, to whom a copy of this report and the Licensee’s Rights (LIC9058 01/16) were provided.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Janet Ngallo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5