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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 421703748
Report Date: 05/19/2025
Date Signed: 05/19/2025 03:21:13 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/29/2025 and conducted by Evaluator Mark Jeffries
COMPLAINT CONTROL NUMBER: 29-AS-20250429162031
FACILITY NAME:PURISIMA HILLSFACILITY NUMBER:
421703748
ADMINISTRATOR:SUSAN MARSHFACILITY TYPE:
740
ADDRESS:237 ALDEBARAN AVENUETELEPHONE:
(805) 733-4395
CITY:LOMPOCSTATE: CAZIP CODE:
93436
CAPACITY:6CENSUS: 3DATE:
05/19/2025
UNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Administrator, Susan MarshTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Licensee did not issue a refund of advance fees as required.


INVESTIGATION FINDINGS:
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 At 2:40pm on 05/19/2025, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to issue final findings to the allegations to this complaint. LPA also conducted a continuation annual review of facility owned and operated by same Administrator next door under a different license number. LPA met with Administrator, Susan Marsh, announce who he is and the reason for the visit.

As to the allegation, “Licensee did not issue a refund of advance fees as required.” It was alleged that facility did not refund deposit of $1250.00 after potential resident was denied admission to the facility. It was discovered that on 05/05/2025, LPA Jeffries conducted an interview with Administrator, Susan Marsh, who stated that they believed that the perspective resident (R1) was being “dumped” by family member (W1) due to W1 flying out of the country the day R1 was negotiated to become a resident at the facility. Administrator stated that W1 did not complete the Admissions Agreement on 04/26/2025 due to lack of power or attorney or conservatorship and R1 was not present at the Admissions Agreement attempted signing.
CONTINUED on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025
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 4
Control Number 29-AS-20250429162031
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: PURISIMA HILLS
FACILITY NUMBER: 421703748
VISIT DATE: 05/19/2025
NARRATIVE
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Administrator stated that R1 and W1 arrived unannounced to the facility on the next day (04/27/2025) without a signed Admission Agreement. At which time Administrator told W1 and R1 that they would not be accepting R1 as a new resident in this facility. On 05/02/2025, LPA Jeffries conducted a phone interview with W1, who stated that they provided Administrator with a check for $1250.00 on 03/31/2025, which was cashed on 04/09/2025. W1 stated that on 04/26/2025 they (W1) were at the facility to sign the admission agreement, however, Administrator would not allow W1 sign without R1 present, and the Admission Agreement did not get signed. W1 stated that on 04/27/2025 they arrived at the facility with R1 and Administrator refused them admission. W1 stated that Administrator only spent 5 minutes talking about photography with R1 and did not do any preadmission's assessment with R1 at any time. W1 stated that the facility has not provided them with any amount of refund. W1 did state that they lost “thousand of dollars” as they had to cancel their flight to Europe due to the refusal of admissions to the facility. LPA observed a handwritten receipt for $1250.00 with memo of, “03/04/2025 to the end of March”. LPA also observed LIC602 Physicians report. LPA conducted a second phone interview on 05/13/2025 with W1 who stated that they still have not received any amount of refund. On 05/19/2025 at 11:49am LPA Jeffries contacted W1 a third time and stated that there had no check issued for any amount. Based on interviews and admission of both Administrator and W1, there is enough evidence to support the allegation of, “Licensee did not issue a refund of advance fees as required.” and is substantiated at this time.

Exit interview, report read, citation and appeal rights provide.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 29-AS-20250429162031
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PURISIMA HILLS
FACILITY NUMBER: 421703748
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/02/2025
Section Cited
CCR
87507(5)(E)1.a.&b.
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87507(5) Refund conditions. (E)Pre- admission fees shall be refunded according to the following conditions:1. A 100 percent refund of a preadmission fee shall be provided to an applicant or the applicant’s representative if: a.The applicant decides not to enter the facility prior to the facility
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Administrator will refund 100% of the deposit to W1 on or before 06/02/2025.Administrator will contact LPA by cell phone, email or fax when depot check has cleared their bank account.
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completing a preadmission appraisal as defined in Section 87457. b. The licensee fails to provide full written disclosure of preadmission fee charges and refund conditions. This regulation was not met by lack of evidence of 100% refund. Which poses a danger to 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: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/29/2025 and conducted by Evaluator Mark Jeffries
COMPLAINT CONTROL NUMBER: 29-AS-20250429162031

FACILITY NAME:PURISIMA HILLSFACILITY NUMBER:
421703748
ADMINISTRATOR:SUSAN MARSHFACILITY TYPE:
740
ADDRESS:237 ALDEBARAN AVENUETELEPHONE:
(805) 733-4395
CITY:LOMPOCSTATE: CAZIP CODE:
93436
CAPACITY:6CENSUS: 3DATE:
05/19/2025
UNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Administrator, Susan MarshTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Licensee did not ensure facility cleanliness was maintained.
INVESTIGATION FINDINGS:
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 As to the allegation of, “Licensee did not ensure facility cleanliness was maintained.” It was alleged that on 04/26/2025, facility walls, doors, and carpets were dirty like they had not been cleaned. It was observed on 05/05/2025 by LPA Jeffries that the facility was clean and in good repair. On 05/05/2025 Tri Counties, Quality Assurance Miguel Magana (QA) made observations of the facility and stated, “its fine.” LPA had conducted an annual inspection of the facility on 02/24/2025 and the facility was clean on that date. At this time there is not enough evidence to support the allegation of, “Licensee did not ensure facility cleanliness was maintained.” And is unsubstantiated at this time.

Exit interview, report read and report provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4