374604545-9-22-2025-18-AS-JDHS-DLZVXT-20250930165004

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604545
Report Date: 09/22/2025
Date Signed: 09/22/2025 11:58:48 AM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/13/2023 and conducted by Evaluator Javina George

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20230713151454

FACILITY NAME:	GARDENS AT ESCONDIDO		FACILITY NUMBER:	374604545
ADMINISTRATOR:	MCBRIDE, FERLINA		FACILITY TYPE:	740
ADDRESS:	1342 NORTH ESCONDIDO BLVD		TELEPHONE:	(760) 480-8155
CITY:	ESCONDIDO	STATE: CA	ZIP CODE:	92026
CAPACITY:	101	CENSUS: 74	DATE:	09/22/2025
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Monica Flores, Executive Director		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Due to staff neglect, resident sustained a burn requiring hospitalization.

INVESTIGATION FINDINGS:

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On 09/22/25 Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to deliver findings for the allegation noted above. LPA met with Monica Flores, Executive Director and explained the purpose of the visit and the elements of the allegation. The allegation was investigated, and the investigation consisted of observations, interviews and records review.

On 07/13/2023 Community Care Licensing received a complaint alleging due to staff neglect, resident sustained a burn requiring hospitalization. Resident #1 (R1) was admitted to the facility on 06/15/2023. On 07/13/2023 during medication pass, R1 was found inside their bedroom in a frog-like position facing downward at the foot of their bed. Staff #1 (S1) checked R1’s vitals and observed R1 to have redness around their calf of their legs, but no blistering. Emergency Services were activated and R1 was sent out and admitted to a local hospital from 07/13/2023 to 08/02/2023.

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Carolyn Tuba
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20230713151454

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GARDENS AT ESCONDIDO	FACILITY NUMBER: 374604545
	VISIT DATE: 09/22/2025

NARRATIVE

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A review of the relevant medical records related to R1’s hospitalization were reviewed. The medical records indicated R1 was not diagnosed with a burn. R1 was diagnosed with injuries related to R1’s health conditions.

The investigation did not provide sufficient evidence that staff neglect caused the injuries R1 was diagnosed with. The investigation further revealed staff obtained timely medical attention for R1’s observed injuries. Therefore, based on interviews and records review the allegation is unfounded. A finding that the complaint is unfounded means the allegation is false, could not have happened, and/or is without a reasonable basis.

An exit interview was conducted where a copy of this report was reviewed and provided to Monica Flores, Executive Director.

SUPERVISORS NAME: Carolyn Tuba
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2025

LIC9099 (FAS) - (06/04)

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