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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 134604299
Report Date: 07/17/2025
Date Signed: 07/17/2025 11:49:41 AM

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
01/27/2023 and conducted by Evaluator Tiffany Holmes
COMPLAINT CONTROL NUMBER: 08-AS-20230127162148
FACILITY NAME:PARKSIDE VILLA ASSISTED LIVINGFACILITY NUMBER:
134604299
ADMINISTRATOR:SIKLALIC GARCIAFACILITY TYPE:
740
ADDRESS:1685 CYPRESS DRTELEPHONE:
(442) 271-4109
CITY:EL CENTROSTATE: CAZIP CODE:
92243
CAPACITY:18CENSUS: 0DATE:
07/17/2025
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:FACILITY IS CLOSEDTIME COMPLETED:
11:50 AM
ALLEGATION(S):
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Neglect resulting in serious bodily injury.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Tiffany Holmes concluded the complaint investigation regarding the above mentioned allegation. The facility is closed, reports mailed certified.

Based on interviews and record reviews, the finding regarding the above allegation was determined to be substantiated. This finding means there is a preponderance of evidence to prove that the alleged violation occurred.

The Department's investigation included interviews and a review of pertinent records. It was alleged that neglect resulting in serious bodily injury occurred. On 1/25/2023, around 7:30 AM, Resident 1 (R1) suffered a fall in their room onto the hard surface floor. Staff 1 (S1) was the only caregiver at the facility at the time in care of fourteen (14) residents most of which are diagnosed with dementia and or are nonambulatory. Interviews revealed that S1 indicated that R1 understands and is capable of following instructions, however R1 usually doesn’t, and will get out of bed without assistance and fall. S1 was escorting R1s roommate to the dining room for breakfast and R1 was seated in their bed. S1 left the room with the roommate and instructed R1 to wait for their return before getting out of bed. Interviews revealed that once S1 left to go to the dining room, they heard a loud thump noise from R1’s room. Upon their return, S1 found R1 on the floor next to their bed.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
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-20230127162148
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: PARKSIDE VILLA ASSISTED LIVING
FACILITY NUMBER: 134604299
VISIT DATE: 07/17/2025
NARRATIVE
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Interviews revealed R1 told S1 they were okay and pled with S1 not to call paramedics. S1 evaluated R1 and did not observe any visual injuries. R1 stood up from the floor on their own and after a telephone conversation with the facility administrator, the decision was made to not call for medical aid. R1 began complaining of hip/groin pain later in the afternoon around 4:00 PM. Interviews revealed R1s Primary Care Physician was notified and an x-ray was scheduled the following day January. 26, 2023. Interviews revealed the primary doctor contacted facility staff on the morning of January. 27, 2023, after getting the x-ray results and instructed staff to immediately get R1 transported to the ER due to a right hip fracture. Interviews revealed that there is no set caregiver to resident ratio at the facility. It is unreasonable that one caregiver can adequately care and supervise 14 elderly residents whereas most of which are non-ambulatory and need individual assistance with their ADLs. It is reasonable, that if S1 had additional assistance, R1’s fall may have been avoided. Therefore, the allegation of neglect resulting in serious bodily injury is substantiated.

Due to the facility’s closure, no exit interview was conducted. A copy of this report, along with Licensee Rights (LIC 9058 03/22), were mailed via USPS certified mail to the last mailing address on file.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 08-AS-20230127162148
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: PARKSIDE VILLA ASSISTED LIVING
FACILITY NUMBER: 134604299
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/17/2025
Section Cited
CCR
87411(a)
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Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement was not met as evidence by:
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FACILITY IS CLOSED
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Based on interviews, the licensee did not ensure facility personnel (S1) was competent to provide the services necessary to meet the needs of 1 of 14 residents which posed an immediate safety risk to persons 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: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3