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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604689
Report Date: 10/02/2025
Date Signed: 10/02/2025 03:39:49 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
01/10/2025 and conducted by Evaluator Rebecca A Borunda
COMPLAINT CONTROL NUMBER: 08-AS-20250110114106
FACILITY NAME:PARKER VILLAFACILITY NUMBER:
374604689
ADMINISTRATOR:LYNN DRUMMONNFACILITY TYPE:
740
ADDRESS:629 MICHAEL STTELEPHONE:
(619) 625-6886
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY:6CENSUS: 6DATE:
10/02/2025
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Caregiver Roy AntesTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Neglect resulting in pressure injury
Licensee did not ensure facility was staffed at night
Staff did not assist resident with medication administration
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegations. LPA identified herself to, was greeted by, and explained the purpose of the visit to Caregiver Roy Antes.

The Department’s investigation consisted of interviews with residents, staff, and outside sources, records review, and a tour of the facility. It was alleged that the Licensee neglected a resident resulting in pressure injuries, Licensee did not ensure that facility was staffed at night, and staff did not assist resident with medication administration. Review of admission paperwork for Resident 1 (R1) revealed that R1 was admitted to the facility in October 2024. Review of resident assessment records dated October 2024 revealed that R1 was not confused or disoriented, had a history of skin breakdown, required assistance with transferring and was not receiving hospice services.
Continued on LIC9099-C page...
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Rebecca A Borunda
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2025
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 7
Control Number 08-AS-20250110114106
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: PARKER VILLA
FACILITY NUMBER: 374604689
VISIT DATE: 10/02/2025
NARRATIVE
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Interviews with R1, staff, and outside sources revealed that R1 was also unable to reposition while in bed and skilled nursing paperwork dated September 2024 revealed that R1 needed to be repositioned every two hours. Interviews with staff and R1 revealed that staff did not initiate repositioning for R1 and instead, R1 had to request assistance with transferring and repositioning, which R1 did not request very often. Interviews with staff and R1 revealed that R1 was receiving wound care from an outside agency in January 2025, however, staff did not have knowledge regarding the name of R1’s outside agency, the frequency of the visits, or specifics regarding R1’s health. Additionally, interviews revealed that the outside agency stopped services in approximately May 2025, due to R1’s pressure injuries being resolved. However, interviews conducted in September 2025 revealed that R1 had at least one pressure injury that was not being treated by an outside agency. Interviews also revealed that facility staff were providing care for R1’s pressure injury.

Review of Resident 2’s (R2) assessment records dated July and August 2023 revealed that R2 was bedridden, had a history of skin breakdown, required assistance with all activities of daily living including repositioning every two hours, and was receiving hospice services. Staff stated during interviews that R2 did not have any pressure injuries, however, R2’s hospice care plan dated August 2023 contradicted this information and stated that R2 had multiple Stage 3 and Stage 4 pressure injuries. Interviews with staff revealed that R2 would be repositioned during the day but R2 would not be repositioned overnight. Staff estimated that R2 would be repositioned around 8:00pm and would not be repositioned until the next morning at around 7:00am, which resulted in R2 not being repositioned for approximately 11 hours. Interviews with residents confirmed that there were no awake staff at the facility overnight and staff did not conduct regular rounds or checks on residents overnight. Review of R2’s hospice care plans in 2025 revealed that R2 still had multiple pressure injuries and R2’s hospice nurse care notes revealed that R2 developed a new pressure injury in late August 2025, however the paperwork did note the stage of the new or already identified pressure injuries.

Interviews revealed that on at least one occasion in January 2025, a staff member working the afternoon shift left the facility before the overnight staff member arrived, resulting in the facility not having any staff supervision for approximately five (5) minutes. Interviews with staff and residents revealed that there were issues with one specific staff member, Staff 1 (S1), giving residents the wrong medications. Residents denied consuming medication that was not prescribed to them due to residents identifying the incorrect medication and informing staff of the mistake.
Continued on LIC9099-C page...
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Rebecca A Borunda
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 08-AS-20250110114106
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: PARKER VILLA
FACILITY NUMBER: 374604689
VISIT DATE: 10/02/2025
NARRATIVE
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Interviews with staff and residents confirmed that S1 was no longer working at the facility as of mid June 2025. [Staff were provided with LIC811 Confidential Names List to identify residents and staff]

The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of the evidence has been met, therefore, these allegations are deemed substantiated. The following deficiencies regarding neglect, absence of supervision, and medication administration are cited per CA Code of Regulations Title 22 and noted on the attached LIC9099-D pages. Additionally, review of past citations issued within a 12 month period revealed that the facility was cited for absence of supervision on 11/19/2024. Therefore, a civil penalty in the amount of $1,000 was issued for a repeat zero tolerance violation within a 12 month period and noted on the attached LIC421IM form. Additionally, the Department has determined that the allegation of neglect resulting in pressure injuries resulted in injuries to a resident in care, therefore, an immediate civil penalty in the amount of $500 is being assessed and noted on a separate attached LIC421IM form. Per Health and Safety Code Section 1569.49, an additional civil penalty is under review by the Program Administrator of the Community Care Licensing Division.

An exit interview was conducted with Caregiver Raymond Abedoza, whose signature below confirms receipt of a copy of this report, the two LIC421IMs forms, and the Licensee Appeal Rights (LIC9058 03/22).
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Rebecca A Borunda
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 08-AS-20250110114106
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: PARKER VILLA
FACILITY NUMBER: 374604689
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
10/10/2025
Section Cited
CCR
87415(a)(1)
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87415 Night Supervision (a)(1) In facilities caring for less than sixteen (16) residents, there shall be a qualified person on call on the premises.
This requirement has not been met as evidenced by:
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Caregiver stated that shifts are from 7am-7pm and 8am-8pm and there is at least one live-in caregiver present at all times, including overnight. Licensee will submit a copy of staff schedule showing 24 hour supervision to the Department by POC due date of 10/10/2025.
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Based on interviews, the Licensee did not ensure that facility staff were present at all times. This poses an immediate safety risk to 6 of 6 residents in care.
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Deficiency Dismissed
Type A
10/03/2025
Section Cited
CCR
87468.2(a)(8)
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87468.2(a)… residents… shall have the following personal rights: (8) to be free from neglect… This requirement has not been met as evidenced by:
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Caregiver stated understanding that R1 and R2 need to be repositioned every two hours, including overnight. Caregiver stated that an outside vendor will provide training regarding repositioning and will submit proof of training to the Department by POC due date of 10/31/2025.
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Based on interviews and records review, the Licensee did not ensure that R1 and R2 were repositioned every 2 hours, resulting in pressure injuries. This poses an immediate health risk to 2 of 6 residents in care.
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Caregiver agreed to create a repositioning tracker to keep record of repositioning of R1 and R2 and will keep a copy of the record within each resident's file.
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: Sabel Martinez
LICENSING EVALUATOR NAME: Rebecca A Borunda
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 08-AS-20250110114106
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: PARKER VILLA
FACILITY NUMBER: 374604689
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/22/2025
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care (a)(4) The licensee shall assist residents with self-administered medications as needed. This requirement has not been met as evidenced by:
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Caregiver stated that an outside vendor conducted medication training on 9/29/2025. Caregiver will submit proof of medication training to the Department by POC due date of 10/22/2025.
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Based on interviews, the Licensee did not ensure that staff correctly assisted residents with medication administration, which poses a potential health risk for 6 of 6 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: Sabel Martinez
LICENSING EVALUATOR NAME: Rebecca A Borunda
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 7
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
01/10/2025 and conducted by Evaluator Rebecca A Borunda
COMPLAINT CONTROL NUMBER: 08-AS-20250110114106

FACILITY NAME:PARKER VILLAFACILITY NUMBER:
374604689
ADMINISTRATOR:LYNN DRUMMONNFACILITY TYPE:
740
ADDRESS:629 MICHAEL STTELEPHONE:
(619) 625-6886
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY:6CENSUS: 6DATE:
10/02/2025
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Caregiver Roy AntesTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff did not provide daily meals to resident
Staff did not treat resident with respect
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegations. LPA identified herself to, was greeted by, and explained the purpose of the visit to Caregiver Roy Antes.

The Department’s investigation consisted of interviews with residents, staff, and outside sources, records review, and a tour of the facility. It was alleged that staff did not provide daily meals to residents. Interviews with residents and staff revealed that the facility provided 3 meals for residents. Interviews with residents revealed complaints that there was no large variety of food, however, the Department was unable to corroborate evidence that residents did not receive 3 meals a day. During onsite visits in January, August, and September 2025, LPA Borunda observed staff cooking and serving meals to residents, as well as residents making inquiries regarding the meals served throughout the day.

Continued on LIC9099-C page...
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Rebecca A Borunda
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 08-AS-20250110114106
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: PARKER VILLA
FACILITY NUMBER: 374604689
VISIT DATE: 10/02/2025
NARRATIVE
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Additionally, interviews with residents and outside sources stated that some residents would purchase meals while out in the community or would purchase food items if residents did not want to eat the meals cooked by staff.

It was alleged that staff did not treat residents with respect. Interviews with staff and residents revealed that at least one resident, Resident 1 (R1) would get upset with staff and yell. Interviews revealed that R1 would also yell during personal care due to pain. However, interviews with outside sources revealed that R1 would get upset and interviews with R1 revealed that R1 had a health condition which could cause R1 to have emotional outbursts. While interviews with R1 alleged that staff did not treat residents with respect, other residents did not corroborate the allegation that staff did not treat residents with dignity. Additionally, staff denied cursing, yelling, or treating residents disrespectfully during interviews.

The Department has investigated the above-mentioned allegations and based on interviews and observations, the preponderance of the evidence has not been met, therefore, these allegations are deemed unsubstantiated.

An exit interview was conducted with Caregiver Raymond Abedoza, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 03/22).
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Rebecca A Borunda
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 7