370808447-9-22-2025-08-AS-SMAZ-DMAR2R-20251009123844

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 370808447
Report Date: 09/22/2025
Date Signed: 09/22/2025 05:50:44 PM

Unsubstantiated

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
08/07/2025 and conducted by Evaluator Marisela Garcia-Centeno

COMPLAINT CONTROL NUMBER: 08-AS-20250807150231

FACILITY NAME:	DEL SUR CRISIS CENTER		FACILITY NUMBER:	370808447
ADMINISTRATOR:	DAY, MICHAEL		FACILITY TYPE:	772
ADDRESS:	892 27TH STREET		TELEPHONE:	(619) 575-4687
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92154
CAPACITY:	12	CENSUS: 10	DATE:	09/22/2025
		UNANNOUNCED	TIME BEGAN:	03:45 PM
MET WITH:	Program Director, Aide Arredondo		TIME COMPLETED:	05:20 PM

ALLEGATION(S):

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Staff did not provide adequate supervision to meet clients' needs
Staff engaged in a verbal altercation with client

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced complaint visit to deliver findings regarding the allegations listed above. LPA met with Program Director, Aide Arredondo, and discussed the results of the investigation.

The Department’s investigation consisted of staff and outside source interviews, record reviews, and review of materials provided as evidence.

On August 7, 2025, it was reported to Community Care Licensing (CCL) that staff did not provide adequate supervision to meet clients’ needs. Details of the complaint included two incidents. Incident 1 alleged that on July 17, 2025, a client (C1) displaying distress was observed on the rooftop because there was a lack of supervision. Incident 2 alleged that on June 26, 2025, the lack of supervision resulted in a client (C2) being taken into custody.
(Continue at LIC9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20250807150231

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: DEL SUR CRISIS CENTER	FACILITY NUMBER: 370808447
	VISIT DATE: 09/22/2025

NARRATIVE

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(continue from LIC9099)

Staff interviews revealed that client C1 was observed on the roof while smoking a cigarette, on July 17. 2025. During multiple interviews, staff explained that they received a phone call from an outside source making derogatory remarks toward the facility, stating that there was a client on the roof.

Staff stated that they immediately went upstairs to Room 2, where C1 was staying, and observed C1 outside on the roof. Staff instructed C1 to come back inside, and C1 complied. C1 explained to staff that they were clearing their head after having been triggered earlier by the same outside source that reported the incident while they were sweeping the patio. Review of records and staff interviews did not reveal evidence of inadequate supervision. Instead, records and interviews showed that staff responded immediately, redirected C1 safely back inside, and ensured that the client was unharmed. Review of C1’s records and progress notes did not indicate that C1 was exhibiting health or safety risk behaviors or attempting self-harm. Staff rounds logs confirmed that safety checks were conducted every 30 minutes as required. Based on the information obtained, there was no evidence to support that the C1’s presence on the roof was caused by inadequate supervision. Staff responded promptly, redirected C1 safely back inside, and ensured the client was unharmed.

During interviews, staff reported that client C2 exhibited behaviors that threatened their health and safety, on June 26,2025. Staff activated 911 emergency procedures, and law enforcement responded to the facility. C2 was transported to the hospital on a 5150 psychiatric hold for further evaluation and treatment to meet their needs. Contrary to the allegation, C2 was not taken into custody. Records confirmed staff provided immediate intervention to prevent self-harm and acted appropriately.

Based on review of records, staff interviews, and observations, there was no evidence that either incident was the result of inadequate supervision. Staff actions were timely and consistent with Title 22 requirements.

(continue at LIC9099C)

SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2025

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20250807150231

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: DEL SUR CRISIS CENTER	FACILITY NUMBER: 370808447
	VISIT DATE: 09/22/2025

NARRATIVE

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(Continue from LIC9099C)

It was also alleged that a staff member engaged in a verbal altercation with a client outside the facility. The date, time or any other details of when the incident occurred were not provided. On September 12, 2025, LPA received images and video clips as evidence to support the allegation. The material provided did not include an audit trail (date, time, or metadata), and the staff and client were not identified.

Review of the recordings showed a client on the street near the facility while staff attempted to redirect the client back inside. Although verbal interaction was observed, the content did not reflect a verbal altercation. The video showed a recording of the outside source asking the client if staff were treating them badly; the client responded “no,” and stated they were attempting to arrange transportation to a medical appointment. The video recording showed that a second staff member joined the interaction, and within moments, the client returned voluntarily into the facility, followed by the staff. The client was observed to be unharmed.

The outside source alleged the client was at risk of being struck by a car. However, the facility is located at the end of an L-shaped cul-de-sac in a residential neighborhood with limited traffic. Review of the videos indicated that staff were present, supervising, and assisting the client throughout the incident. Although the client was observed to be walking on the street, there was no immediate harm, and the client returned to the sidewalk.

The evidence reviewed did not demonstrate mistreatment or violation of personal rights. Staff actions observed were consistent with Title 22 supervision.

Based on interviews, record reviews, and evidence submitted, there was insufficient evidence to corroborate the allegations. Although the incidents may have occurred, the preponderance of evidence standard was not met. Therefore, both allegations were Unsubstantiated.

An exit interview was conducted with Program Director Aide Arredondo. A copy of this report and Licensee Rights (LIC 9058 03/22) were provided at the conclusion of the visit.

SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2025

LIC9099 (FAS) - (06/04)

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