374604788-9-10-2025-08-AS-SJAB-DLFRC2-20250912125337

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604788
Report Date: 08/27/2025
Date Signed: 09/10/2025 10:57:23 AM

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
07/31/2025 and conducted by Evaluator Amy Domingo

COMPLAINT CONTROL NUMBER: 08-AS-20250731101333

FACILITY NAME:	ROCK OF AGES MANOR CARE		FACILITY NUMBER:	374604788
ADMINISTRATOR:	EVANGELISTA, MARYL		FACILITY TYPE:	740
ADDRESS:	7445 PACIFIC AVENUE		TELEPHONE:	(619) 844-4566
CITY:	LEMON GROVE	STATE: CA	ZIP CODE:	91945
CAPACITY:	6	CENSUS: 4	DATE:	08/27/2025
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Maryl Evangelista, Administrator		TIME COMPLETED:	11:44 PM

ALLEGATION(S):

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Staff are not mitigating the spread of infectious outbreaks in the facility.
Staff are not providing residents with adequate hand-washing supplies

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to deliver the findings in the above-mentioned complaint allegations. LPA Domingo identified herself and discussed the purpose of the visit with Administrator Maryl Evangelista Administrator .

During the investigation, LPA Domingo collected pertinent resident records as well as facility documentation and conducted interviews with staff, residents, and outside sources.

On July 31, 2025, the department received a complaint alleging that the facility staff are not mitigating the spread of infectious outbreaks in the facility and that staff are not providing residents with adequate hand washing supplies.

(Continued on LIC9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2025

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 3

Control Number 08-AS-20250731101333

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: ROCK OF AGES MANOR CARE	FACILITY NUMBER: 374604788
	VISIT DATE: 08/27/2025

NARRATIVE

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(Continued from LIC9099 2 of 3)

Interviews were conducted with three (3) residents. Residents reported that they feel safe and that staff are proactive in preventing the spread of infections. Resident 1 (R1), mentioned, "The staff always reminds us to wash our hands and provides us with hand sanitizer."

Interviews were conducted with three (3) outside sources. Family members confirmed that they have observed staff following proper infection control procedures and providing adequate hand washing supplies.

Interviews were conducted with two (2) staff members. Staff members confirmed that infection control measures, such as regular hand washing, use of personal protective equipment (PPE), and isolation protocols, are consistently followed. One Staff 1 (S1), stated, "We are very diligent about following infection control protocols to keep everyone safe."

Interviews were conducted with staff members, residents, and outside sources. All interviewees confirmed that infection control measures, such as regular hand washing, use of personal protective equipment (PPE), and isolation protocols, are consistently followed.

During the visit, multiple areas of the facility were observed. Staff were seen adhering to infection control protocols, practicing hand hygiene, and following isolation procedures for affected individuals. Hand washing stations throughout the facility were observed to be adequately stocked with soap, paper towels, and hand sanitizer. Staff were observed replenishing supplies as needed.

A review of infection control logs, training records, and appropriate measures to mitigate the spread of infectious outbreaks. No significant lapses were identified.
The facility's policies on infection control and hand hygiene were reviewed and found to be comprehensive and in compliance with Title 22 and California Health and Safety regulations. Previous compliance audits and inspections showed no issues related to infection control practices or the provision of hand washing supplies.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2025

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20250731101333

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: ROCK OF AGES MANOR CARE	FACILITY NUMBER: 374604788
	VISIT DATE: 08/27/2025

NARRATIVE

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Continued from LIC9099 3 of 3)

It was alleged that staff not providing adequate hand washing supplies.

Interviews were conducted with two staff members, three (3) residents, and two (2) outside sources. All interviewees confirmed that hand washing supplies (soap, paper towels, hand sanitizer) are consistently available in all necessary areas.

During the visit, multiple hand washing stations were observed. All stations were adequately stocked with soap, paper towels, and hand sanitizer.

A review of supply orders and inventory records for the past 6 months showed regular and sufficient ordering of hand washing supplies. No discrepancies were found.

The facility's hand hygiene policy was reviewed and found to be comprehensive and up-to-date. Previous compliance audits showed no issues related to hand washing supplies.

This Department has investigated the above complaint allegations. The Department has found that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur; therefore, the allegations are UNSUBSTANTIATED.

An exit interview was conducted, and a copy of this report and licensee rights (LIC 9058 03/22). Administrator's signature on this form confirms receipt of these rights.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2025

LIC9099 (FAS) - (06/04)

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