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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604839
Report Date: 09/05/2025
Date Signed: 09/05/2025 08:05:51 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
08/27/2025 and conducted by Evaluator Carmen Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20250827145528
FACILITY NAME:CASA DE CASTRO IIIFACILITY NUMBER:
374604839
ADMINISTRATOR:CASTRO, CELESTE & CHERYLFACILITY TYPE:
740
ADDRESS:319 S SIENA STTELEPHONE:
(619) 857-6945
CITY:SAN DIEGOSTATE: CAZIP CODE:
92114
CAPACITY:6CENSUS: 5DATE:
09/05/2025
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Cheryl Castro, LicenseeTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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- Facility staff do not treat residents with dignity
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced complaint visit to open a complaint investigation. While at the facility, LPA investigated and delivered findings regarding the above-mentioned allegation. LPA identified herself and was granted entry by Elizabeth Lim, caregiver. LPA stated the purpose of the visit and reviewed the findings of the complaint with Licensee Cheryl Castro, who later arrived and joined the visit.

The Department’s investigation consisted of interviews with staff and residents, and records review of relevant documents pertinent to this investigation. On August 27, 2025, it was said that the facility staff do not treat residents with dignity.

It was specifically said that staff #1 (S1) and staff #2 (S2) verbally mistreated a resident in a different language due to R1’s incontinence issues by yelling, screaming and being disrespectful to R1.

(Continuationo on LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2025
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-20250827145528
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: CASA DE CASTRO III
FACILITY NUMBER: 374604839
VISIT DATE: 09/05/2025
NARRATIVE
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(Continuation of LIC9099)

During the investigation, LPA spoke with staff and residents who confirmed that there has been yelling occurring at the facility. According to residents (R1, R2, and R5), S1 has yelled at resident(s). According to R4, they have not heard yelling but acknowledged that S1 is always rushed and in a hurry. According to staff, they confirmed that they do yell in a different language but towards each other, S1 and S2, and not to residents. S1 said that they only spoke with R3 regarding their incontinence and not to defecate on their bed. Resident records show that R1, R2, R4, and R5’s mental conditions are good, and they are able to follow instructions and communicate their needs and are not confused or disoriented. LPA’s observations of the residents were coherent and sound of mind. They all spoke clearly during their interviews.

Based on the Department’s investigation of the above-mentioned allegation and the evidence obtained during staff and resident interviews, records reviewed, and LPA observations, there is sufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegation is deemed to be substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC9099-D page of this report.

The report was discussed, plan of correction was jointly developed, and an exit interview was conducted with Licensee Cheryl Castro. A copy of this report along with Licensee/Appeal Rights (LIC9058 3/22) were provided to Licensee Castro at the conclusion of the visit. The signature below confirms the receipt of these documents.
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20250827145528
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: CASA DE CASTRO III
FACILITY NUMBER: 374604839
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/19/2025
Section Cited
CCR
87468.2(a)(8)
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87468.2 (a)(8) Additional Personal Rights of Residents in All Facilities: (8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse.… this requirement was not met as evidence by:
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Licensee agreed to speak with the staff and document it and send the document to LPA by POC due date, 09/19/2025.
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Based on interviews, staff yelled while working at the facility which affected 5 of 5 resident in care which posed a potential personal rights risk to 5 of 5 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: Robyn Clark
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3