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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 370800930
Report Date: 08/20/2025
Date Signed: 08/20/2025 01:13:27 PM

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
08/18/2025 and conducted by Evaluator Iby Strong
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20250818163624
FACILITY NAME:ST MADELEINE SOPHIES CENTERFACILITY NUMBER:
370800930
ADMINISTRATOR:DEBRA EMERSONFACILITY TYPE:
775
ADDRESS:2119 E. MADISON AVENUETELEPHONE:
(619) 442-5129
CITY:EL CAJONSTATE: CAZIP CODE:
92019
CAPACITY:400CENSUS: 360DATE:
08/20/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Director Mark FisherTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Lack of staff supervision resulted in client on client sexual activity.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Iby Strong conducted an unannounced complaint visit to initiate an investigation on the above-mentioned allegation. LPA met with Director Mark Fisher and discussed the purpose of the visit.

During investigation, LPA Strong collected pertinent facility documentation and conducted interviews. On August 18, 2025, Community Care Licensing (CCL) received a complaint alleging, on an undisclosed date, Client 1 and Client 2 were left unsupervised resulting in sexual activity between the two clients. Records collected revealed that on August 4, 2025, C1 and C2 were observed to be near or around the restroom by Staff 1 (S1), then later that day C1 reported the sexual activity to another staff. Interview with staff present on the day of the incident revealed that there were roughly 20 clients to one staff in the Upper Pavilion/Gazebo area. Records collected corroborated that on August 4, 2025, Staff 1 was scheduled to have a morning class with 20 clients then an afternoon class with another group of 20 clients with no additional staff.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
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-20250818163624
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: ST MADELEINE SOPHIES CENTER
FACILITY NUMBER: 370800930
VISIT DATE: 08/20/2025
NARRATIVE
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Interview with multiple staff revealed that there were no additional staff or volunteers present to meet day program ratios on that date specific.

Based on interviews, and records reviewed, a preponderance of evidence exists to support the allegations. Deficiencies are being cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). An exit interview was conducted with Director Mark Fisher, CEO Deborah Emerson, and Program Manager Eva Tan to whom a copy of this report, LIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20250818163624
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: ST MADELEINE SOPHIES CENTER
FACILITY NUMBER: 370800930
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/03/2025
Section Cited
CCR
82065.5(b)
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82065.5 Staff-Client Ratio
(b) There shall be an overall ratio of not less than one direct care staff member providing care and supervision for each group of eight clients, or fraction thereof, present.

This requirement was not met as in evidence
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Licensee will provide an updated schedule to LPA via email to show updated ratio scheduling.
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Based on records and interviews the licensee did not maintain a client to staff in 20 persons in care which posed a potential 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: Iby Strong
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3