370808482-8-11-2025-08-AS-SJAB-DKPU2L-20250819151207

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 370808482
Report Date: 08/11/2025
Date Signed: 08/11/2025 01:05:39 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
03/02/2023 and conducted by Evaluator Amy Domingo

COMPLAINT CONTROL NUMBER: 08-AS-20230302145607

FACILITY NAME:	DSC - VILLAGE HOUSE		FACILITY NUMBER:	370808482
ADMINISTRATOR:	KRISTEN HOLLOBAUGH		FACILITY TYPE:	735
ADDRESS:	6010 HOWELL		TELEPHONE:	(619) 697-1611
CITY:	LA MESA	STATE: CA	ZIP CODE:	91942
CAPACITY:	6	CENSUS: 6	DATE:	08/11/2025
		UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Kristen Hollobaugh Administrator		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff hit Client

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to deliver the findings in the above-mentioned complaint allegations. LPA Domingo identified herself and discussed the purpose of the visit with the Administrator, Kristen Hollobaugh.
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During the investigation, LPA Domingo collected pertinent resident records as well as facility documentation and conducted interviews with staff, residents, and outside sources.

On March 2, 2023 it was alleged that Resident 1 (R1) was hit by a staff member.
Records reviewed verified that R1 has moderate ID and behavioral conditions. R1 has poor memory recall. R1 has a needs and service plan for stating events that did not happen.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2025

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-20230302145607

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: DSC - VILLAGE HOUSE	FACILITY NUMBER: 370808482
	VISIT DATE: 08/11/2025

NARRATIVE

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(Continued from LIC9099)

R1 disclosed to Outside Source 1 (OS1) that they no longer felt pain from the slap on the face. OS1 recalled observing a red mark on R1's eye to their ear, but thought nothing of the mark when they first saw the mark. OS1 stated that there have not been any reports of staff hitting any residents. OS1 stated that R1 has not stated that anyone has mistreated them.

Staff 1 was interviewed and stated that they did not observe any marks on R1's face during the time of R1's reporting of a staff member slapping their face. S1 stated R1 has difficulty with memory recall or using the right words to say how they feel.

Staff 2 (S2) was interviewed and stated they did not observe any marks on R1's face. S2 stated that R1 has not verbalized anything about not liking the facility or the staff. S2 stated R2 has a history of poor memory recall and misuse of words to describe how they are feeling.

Resident 2 (R2) was interviewed, and they reported that they have not experienced or witnessed any staff hitting residents. They expressed feeling safe and well treated by the staff.

Outside Source 2 (OS2) was interviewed and confirmed that they have not observed inappropriate behavior by staff towards residents and have no concerns about the treatment of their loved ones.

The department has investigated a complaint alleging that a staff hit a resident. The Department has found that although the allegation may have occurred or be valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur; therefore, the allegation is unsubstantiated.

An exit interview was conducted, and a copy of this report and licensee rights (LIC 9058 03/22) was provided. Administrator Kristen Hollobaugh, on this form, confirms receipt of these rights.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2025

LIC9099 (FAS) - (06/04)

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