374604796-7-31-2025-08-AS-SJAB-DKVUY8-20250825155927

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604796
Report Date: 07/31/2025
Date Signed: 07/31/2025 05:16:05 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
07/23/2025 and conducted by Evaluator Dang Nguyen

COMPLAINT CONTROL NUMBER: 08-AS-20250723091306

FACILITY NAME:	EL CAJON ELDER CARE		FACILITY NUMBER:	374604796
ADMINISTRATOR:	SEQUEIRA, JENIFER		FACILITY TYPE:	740
ADDRESS:	1412 GROVELAND TERRACE		TELEPHONE:	(619) 541-3179
CITY:	EL CAJON	STATE: CA	ZIP CODE:	92021
CAPACITY:	6	CENSUS: 6	DATE:	07/31/2025
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Caregiver Armando Guido-Manjarrez and Licensee/Administrator Jenifer Sequeira		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Licensee's staff physically/sexually abused resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced visit to commence a Complaint Investigation regarding the above allegation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Armando Guido-Manjarrez. LPA then met and discussed the purpose of the visit with Licensee/Administrator Jenifer Sequeira, who arrived shortly after.

The Complainant alleged that Licensee’s staff physically/sexually abused Resident #1 (R1). [See LIC 811 Confidential Names List for a description of R1.] CCLD’s investigation involved an unannounced facility tour/welfare check and interviews of R1, multiple fellow residents/housemates, multiple pertinent facility staff, and neutral outside sources. LPA also reviewed relevant care records for R1.

According to R1’s latest LIC602 Physician’s Report, R1’s primary diagnoses included Schizoaffective Disorder Bipolar Type, Major Depressive Disorder, Insomnia due to Mental Disorder, and Mild Cognitive Impairment (MCI), among others. [CONTINUED ON LIC 9099-C]

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025

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 08-AS-20250723091306

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: EL CAJON ELDER CARE	FACILITY NUMBER: 374604796
	VISIT DATE: 07/31/2025

NARRATIVE

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[CONTINUED FROM LIC 9099] Their doctor wrote that while R1 was able to follow instructions and able to communicate their needs, R1 was also confused/disoriented. R1 was non-ambulatory and relied on staff assistance with dressing, bathing, and changing their incontinence briefs.

The Complainant did not have direct knowledge of the allegation but rather relied on R1’s statements. In their own interview with LPA, R1 was disoriented to time and displayed repeated non-tangential thinking. There were also significant inconsistencies/contradictions and reversals in R1’s narrative of the incident. Nonetheless, R1 was able to say a male facility staff had kissed them repeatedly on the cheek, then groped their breasts under their shirt while they were in bed at the facility. R1 could not say if this occurred once, or more than once. R1 initially declined to identify their perpetrator by name, but answered questions about the perpetrator’s physical appearance characteristics. R1 subsequently provided a name to LPA.

Review of the staff and resident rosters, corroborated by manager and caregiver interviews, showed: There were no staff or residents matching the name which R1 provided. There were also no staff or residents who resembled the physical appearance profile which R1 provided. Staff who were interviewed unanimously reported that R1 was sometimes very confused and that they had never seen any coworker kiss, grope, or physically/sexually abuse any resident in care. They also denied abusing any resident, themselves.

LPA also interviewed 3 of 6 housemates who were present at the facility (the other two residents were at the hospital), finding no evidence/suggestion that R1 or any resident had been physically/sexually abused by facility staff. Residents were complimentary of the care they received.

Prior to CCLD’s involvement, the Long-Term Care Ombudsman’s office independently investigated the same allegation involving R1, determining that it was unsubstantiated.

Based on records and interviews, a preponderance of evidence does not exist to show that Licensee's staff physically/sexually abused resident. The allegation is therefore Unsubstantiated, and no deficiency was cited.

An exit interview was conducted with Licensee/Administrator Jenifer Sequeira, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025

LIC9099 (FAS) - (06/04)

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