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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 421703748
Report Date: 11/19/2025
Date Signed: 11/19/2025 12:24:45 PM

Unsubstantiated


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
11/14/2025 and conducted by Evaluator Mark Jeffries
COMPLAINT CONTROL NUMBER: 29-AS-20251114154010
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: 5DATE:
11/19/2025
UNANNOUNCEDTIME BEGAN:
11:37 AM
MET WITH:Administrator, uTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Staff mismanaged resident's medication.
INVESTIGATION FINDINGS:
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 At 11:35am on 11/19/2025, Licednsing Program Analyst (LPA) Jeffries arrived to the facility unannounced to address the allegation to this complaint. LPA met with facility Administrator, Susan Marsh, announced who he is and the reason for the visit.
LPA conducted a cursory medication audit of medications pertaining to the allegation to this complaint. LPA noted that the Medication Administration Record (MAR) indicated that Resident 1 (R1) MAR November of 2025 entries were noted for the medication in question to the allegation. LPA observed the facility Centrally Stored Medication Record (CSMR) for R1 that noted entry of "18 Pills" and "Plus 50". LPA noted that there were a total of 50 pills counted during medication audit, in addition to the 18 MAR entries equalling the total on the CSMR.
At to the allegation of, "Staff mismanaged resident medication." It was alleged that on Novermber 11, 2025 facility only had 9 of 50 pills of medication noted in allegation. On 11/18/2025,Family Member 1 (F1)
emailed LPA photographs of medication in question during the initial transfer between F1 and facility staff.
CONTINUED on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2025
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 2
Control Number 29-AS-20251114154010
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: 11/19/2025
NARRATIVE
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*AMENDED*
LPA noted that the pharmacy receipt photographed by F1 noted two boxes of medication in question at a quantity of 50 pills per each box. At the top of the photo there was a highlighted note "1 box qty.50-to (Administrator)" and "1 box qty.50- (F1) Kept" On 11/18/2025 LPA conducted a phone interview with F1 who stated that they provided the facility with one box of 50 and kept one box of 50 of the medication in question; as noted on the photograph provided by F1. On 11/19/2025 LPA Jeffries conducted a cursory medication audit of medication in question to the allegation to this complaint. LPA Jeffries noted that the Medication Administration Record (MAR) Resident 1 (R1) for November 2025; MAR shows 18 entries were noted for the medication in question to the allegation. LPA observed the facility Centrally Stored Medication Record (CSMR) for R1 that noted entry of "18 Pills" and "Plus 50" were entered into the CSMR. LPA noted that there were a total of 50 pills counted during medication audit, in addition to the 18 MAR entries equalling the total on the CSMR, showing that the correct pill count for the medication in question was noted from MAR, CSMR and physical medication audit by LPA. Based on interview with F1, MAR, CSMR, and physical medication audit by LPA there is not enough evidence to support the allegation of "Staff mismanaged resident's medication." and is unsubstantiated at this time.

Exit interview, report read, and report provided.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2