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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336423838
Report Date: 02/25/2025
Date Signed: 02/25/2025 12:35:11 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/22/2021 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210622164223
FACILITY NAME:GYPSUM CREEK HOME #2FACILITY NUMBER:
336423838
ADMINISTRATOR:LILIAN TOLENTINOFACILITY TYPE:
735
ADDRESS:14572 SLEEPY CREEK DRIVETELEPHONE:
(951) 220-7499
CITY:CORONASTATE: CAZIP CODE:
92880
CAPACITY:6CENSUS: 6DATE:
02/25/2025
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Administrator Carlito TanTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Staff neglect resulted in client #1 (C1) sustaining injuries.
INVESTIGATION FINDINGS:
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On 02/25/2025, Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the facility to deliver complaint investigation findings for the above allegation. After introducing and identifying self, LPA met Administrator Carlito Tan to discuss the findings.

On June 22, 2021, the Department received a complaint with allegation of neglect resulting in C1 sustaining injuries (multiple fractures). The Department investigation consisted of review of facility and other records, observations, and interviews with pertinent individuals.

Investigation revealed that on June 21, 2021, C1 was sent to local hospital due to left shin and ankle redness. Per medical records, it was indicated that C1 had multiple fractures, fracture of tibial shaft and left fibular fracture. Per interviews, facility staff did not report observation of a fall and could not explain how injury occurred. According to medical staff, ***Continution in LIC9099C***


Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025
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 18-AS-20210622164223
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: GYPSUM CREEK HOME #2
FACILITY NUMBER: 336423838
VISIT DATE: 02/25/2025
NARRATIVE
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C1’s injuries were consistent with a fall or some type of stress.

Per medical records, C1 has had frequent falls in the past (prior to June 22, 2021) and it was reported in record that facility staff were not sure if C1 had follow-up when falls occurred. Investigation further revealed that C1 is non-verbal, needs two staff to assist with ambulating, and utilized a wheelchair. According to multiple interviews, C1 was prone to falling. As reported, C1 would jump up while sitting down and let self-fall while on couch or while staff were changing C1 clothes. Interviews also revealed that C1 needs “a lot” of supervision and caregiver assistance with everything. Staff interviews confirmed that C1 also needs assistance with care needs including bathing, toileting, dressing, and feeding.

Although staff reported that C1 would be checked every thirty minutes or more, depending on the day C1 was having, there was no “set schedule.” Other staff reported that C1 would be checked when in bedroom, because C1 would “pretty often” attempt to get out of bed. It was also reported that there was discussion about one-on-one caregiver for C1. However, investigation did not reveal that C1 was provided with this service.

Overall, the preponderance of evidence supports that facility staff failed to ensure that C1 needs were being met. It was found that C1 was known to have frequent falls and required assistance with care needs. However, there is lack of support to identify that a care plan and/or assistance was in place and followed to meet C1 needs. As a result, on or around June 21, 2021, while at the facility, C1 sustained multiple fractures.

The above allegation is found to be SUBSTANTIATED. A deficiency is being issued per California Code of Regulations, Title 22. A substantiated finding means that the allegation is valid because the preponderance of evidence standard has been met.

In addition, this violation posed an immediate Health and Safety risk to resident(s) in care. An Immediate Civil Penalty of $500 is being assessed. The licensee was also informed that a civil penalty may be assessed based on Health and Safety Code § 1548.



An exit interview was conducted where this report, LIC9099D, LIC421IM, and appeal rights were discussed and provided to the Administrator Carlito Tan..
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20210622164223
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: GYPSUM CREEK HOME #2
FACILITY NUMBER: 336423838
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/26/2025
Section Cited
CCR
85075.4(a)(b)(c)
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85075.4 Observation of the Client (a) The licensee shall regularly observe each client for changes in physical...(b) The licensee shall provide assistance when observation reveals needs… (c)The licensee shall bring observed changes...This requirement was not met as evidenced by:
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Licensee stated to train all staff on CCR 85075.4(a)(b)(c) and submit proof of Training Log to LPA Brown by the Plan of Correction (POC) due date.
Licensee stated to submit signed Statement of Understanding on CCR 85075.4(a)(b)(c) and submit to LPA Brown by POC due date.
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Based upon interviews, C1 sustained injuries at facility which were not observed nor C1 assisted with receiving care as needed which pose immediate health, safety, and personal rights risk to client 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: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025
LIC9099 (FAS) - (06/04)
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