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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604505
Report Date: 09/15/2023
Date Signed: 09/15/2023 03:40:52 PM

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
08/18/2023 and conducted by Evaluator Sabel Martinez
COMPLAINT CONTROL NUMBER: 08-AS-20230818114203
FACILITY NAME:UC SENIOR CARE IVFACILITY NUMBER:
374604505
ADMINISTRATOR:KELLY, FLORAFACILITY TYPE:
740
ADDRESS:3810 GOVERNOR DRIVETELEPHONE:
(858) 583-6431
CITY:SAN DIEGOSTATE: CAZIP CODE:
92122
CAPACITY:6CENSUS: 5DATE:
09/15/2023
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Caregiver, Oscar BojorquezTIME COMPLETED:
03:50 PM
ALLEGATION(S):
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Illegal Eviction
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced complaint investigation visit to deliver complaint findings. The LPA introduced himself and disclosed the purpose of the visit to Caregiver, Oscar Bojorquez,

Throughout the investigation, the Department secured pertinent records and conducted interviews with internal and external sources.

It was alleged a resident was illegally evicted. It was reported to the Department the facility staff had advised Resident # 1‘s (R1) responsible party to move R1 to a different facility. It was reported this was again mentioned during a meeting with R1’s care team.
Interviews with internal sources did not reveal any concerns regarding R1 illegally evicted from the facility. Interviews with external sources revealed R1’s responsible party had made the decision to move R1 to a different facility.
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023
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 2
Control Number 08-AS-20230818114203
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: UC SENIOR CARE IV
FACILITY NUMBER: 374604505
VISIT DATE: 09/15/2023
NARRATIVE
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 Additionally, during the meeting in question, the facility staff did not mention R1 needed to be moved, but instead suggested it should be considered, if R1 and R1’s responsible were not happy at the facility.

Based on the evidenced obtained during the investigation, there was not a preponderance of evidence to prove the alleged violation occurred, therefore, the allegation was unsubstantiated.

An exit interview was conducted with Bojorquez, to whom a copy of this report, and Licensee/Appeals Rights (LIC 9058) were provided.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2