374600578-3-5-2026-18-AS-RORN-DSAKNE-20260318080301

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374600578
Report Date: 03/05/2026
Date Signed: 03/05/2026 12:43:12 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/16/2022 and conducted by Evaluator Antonine Richard

COMPLAINT CONTROL NUMBER: 18-AS-20220616170620

FACILITY NAME:	RANCHO PACIFICA HOME		FACILITY NUMBER:	374600578
ADMINISTRATOR:	CHRISTINA GRUBBS		FACILITY TYPE:	735
ADDRESS:	1229 RANCHO PACIFICA PLACE		TELEPHONE:	(760) 758-9614
CITY:	VISTA	STATE: CA	ZIP CODE:	92084
CAPACITY:	6	CENSUS: 6	DATE:	03/05/2026
		UNANNOUNCED	TIME BEGAN:	08:44 AM
MET WITH:	Brenda Cruz		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Resident sustained injuries while in care.

INVESTIGATION FINDINGS:

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On March 5, 2026, Licensing Program Analyst (LPA), conducted announced a complaint visit regarding the facility above. LPA Richard met with the Administrator (A1) Brenda Cruz, and the purpose of the visit was explained. LPA was granted entry. LPA and Administrator toured the facility.

The Investigation consisted of the following: On March 5, 2026, LPA Richard reviewed and obtained resident Roster, staff roster. LPA also obtained documents for R1’ s Face Sheet, Admission Agreement, Physician quarterly reports, Behavioral Assessment, Appraisal Needs and Services Plan, Unusual Incident Injuries reports, and Facility Progress notes, and a copy of R1 death report. LPA Interviewed two Administrators (A1-A2), three staff (S1-S3), two residents (C2-C3), LPA was unable to interview C4, C5 and C6 due to cognitive impairment. LPA also was unable to interview R1 due to R1 passing away on 10/11/2022.

Report continued on LIC9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Antonine Richard
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 03/05/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2026

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 18-AS-20220616170620

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: RANCHO PACIFICA HOME	FACILITY NUMBER: 374600578
	VISIT DATE: 03/05/2026

NARRATIVE

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Allegation: Resident sustained injuries while in care.

The complaint alleged that the client has bruising on the right ear and above the right eye. On March 05, 2026, LPA interviewed the Administrators (A1), and (A2) both of whom denied the allegation and stated the C1 has a habit of aggressively tapping the hand to the face. On the same day, LPA interviewed three staff members (S1-S3), all of whom denied the allegation and stated that C1 was very active, pinching, and hitting themselves in the face. Additionally, LPA interviewed two clients (C2-C3), all of whom like living here and stated the staff treats them well. LPA records reviewed by the physician for quarterly reports and the behavioral assessment indicate that C1’s behaviors are physical aggression, outburst, grabbing and hitting oneself. LPA also reviewed the facility’s progress notes that showed that C1 sometimes had aggressive behavior toward staff, self, clients and destroying furniture. LPA also reviewed the Unusual Incident Reports sent to Community Care Licensing Department (CCLD) on 06/01/2022, and all the appropriate parties were notified.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

No deficiencies.

An exit interview conducted. A copy of the report was provided to the Administrator Brenda Cruz.

SUPERVISORS NAME: Antonine Richard
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 03/05/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2026

LIC9099 (FAS) - (06/04)

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