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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 421703870
Report Date: 05/05/2025
Date Signed: 05/05/2025 11:27:36 AM

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
02/04/2025 and conducted by Evaluator Mark Jeffries
COMPLAINT CONTROL NUMBER: 29-AS-20250204162504
FACILITY NAME:MARSH'S BOARD & CAREFACILITY NUMBER:
421703870
ADMINISTRATOR:MARSH,SUSAN 98FACILITY TYPE:
740
ADDRESS:233 ALDEBARAN AVENUETELEPHONE:
(805) 733-2231
CITY:LOMPOCSTATE: CAZIP CODE:
93436
CAPACITY:5CENSUS: 1DATE:
05/05/2025
UNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Administrator, Susan MarshTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff violated client's personal rights.
INVESTIGATION FINDINGS:
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 At 8:20am on 05/05/2025, Licensing Program Analyst (LPA) Jeffries arrived at the facility unannounced to issue final findings to the allegation to this complaint. LPA was accompanied by Tri Counties Regional Center (TCRC) QA, Miguel Magana (QA). QA and LPA met with Administrator, Susan Marsh, announced who they are and the reason for the visit, to issue final findings to the allegation to this complaint.

As to the allegation of, “Staff violated client's personal rights.” It was alleged that during a doctor’s visit Resident 1 (R1) was treated rough by staff in removing R1’s sweater, and staff slapped R1 on the face. It was discovered through interviews conducted by LPA Jeffries on 02/05/2025, with facility Administrator, Susan Marsh stated that during a recent doctor’s visit, she had difficulty pulling R1’s sweater off due to R1’s glasses getting caught in the sweater and may have appeared to be forceful. Administrator denied slapping R1. In an interview by LPA Jeffries of a reliable witness (W1) (a person with medical license indicating expertise training and experience) by phone on 02/06/2025, W1 stated that,
CONTINUED on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

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

DATE: 05/05/2025
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 29-AS-20250204162504
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: MARSH'S BOARD & CARE
FACILITY NUMBER: 421703870
VISIT DATE: 05/05/2025
NARRATIVE
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“Ms. Marsh used R1’s arms as leverage and pulled R1’s sweater off in a forceful and rough manor.” W1 also stated that she, “heard a slap and when I (W1) turned around, I witnessed her (Ms. Marsh) slap R1 on the face.” When LPA asked if W1 if they were certain that it was a slap on R1’s face, W1 stated, “1000%”. W1 also stated that there was a medical evaluation after the slap occurred and there were no red marks on the face. On 02/07/2025, LPA Jeffries conducted a phone interview with Health Care Worker (W2) who stated, they did not see the slaps but did witness the sweater being pulled of R1 “very roughly”. On 02/05/2025, QA Magana interviewed R1, with limited verbal answers 4 of 10 questions, that yielded “no response” answers to questions regarding this incident. At this time, based on the 02/05/2025 interview of the credible witness, there is enough evidence to support the allegation of,” Staff violated client's personal rights.” and is substantiated at this time.

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

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

DATE: 05/05/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20250204162504
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: MARSH'S BOARD & CARE
FACILITY NUMBER: 421703870
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/19/2025
Section Cited
CCR
87468.1(a)(1)
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87468.1(a)(1) Personal Rights of Residents in All Facilities. (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
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Administrator will conduct 2 hours of personal rights training with a vender approved by Tri Counties Regional Center (TCRC) and Community Care Licensing (CCL) within two weeks of this citation. Administrator will report to TCRC and CCL with certificate of completion of training.
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This requirement was not met by evidence of a reliable witness observed Administrator slap R1 on the face, which poses a potential risk 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: 05/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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