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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374601291
Report Date: 10/22/2025
Date Signed: 10/23/2025 09:00:21 AM

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
11/02/2022 and conducted by Evaluator Sparkle Day
COMPLAINT CONTROL NUMBER: 18-AS-20221102171633
FACILITY NAME:FOREST VIEW GUEST HOMEFACILITY NUMBER:
374601291
ADMINISTRATOR:DILLARD-BENDER, CAREY M.FACILITY TYPE:
740
ADDRESS:1145 EVERGREEN LANETELEPHONE:
(760) 945-4779
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY:0CENSUS: DATE:
10/22/2025
UNANNOUNCEDTIME BEGAN:
08:13 AM
MET WITH:TIME COMPLETED:
08:14 AM
ALLEGATION(S):
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Facility staff did not follow residents care plan.
Facility staff did not assist resident with hygiene care.
Facility staff spoke inappropriately in the presence of residents.
INVESTIGATION FINDINGS:
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On November 08, 2022, Licensing Program Analyst (LPA), Venus Mixson conducted an unannounced visit to the facility in order to initiate an investigation into the listed allegations. Upon arrival, LPA Mixson observed the facility to be vacant.
The investigation consisted of the following:

Allegation #1: Facility staff did not follow residents care plan
It is alleged that the facility did not follow the resident's physician's orders regarding changing the bandages of a pressure injury.
LPA Mixson attempted to contact the Licensee/Administrator at the provided contact numbers without success. Community Care Licensing (CCL) staff have attempted to make contact via phone numbers and email on file of facility without success.
On10/22/2025 Licensing Program Analyst Sparkle Day began the follow up investigation. LPA Day observed this facility Closed on 11/16/2022. LPA Day attempted to call reporting party and did not get a response after 3 attempts. LPA Day attempted to call facility phone number and Licensee phone number and was unable
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Sparkle Day
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2025
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-20221102171633
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: FOREST VIEW GUEST HOME
FACILITY NUMBER: 374601291
VISIT DATE: 10/22/2025
NARRATIVE
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to reach anyone. LPA Day attempted to reach new placement allegedly R#1 moved to, however after 3 attempts LPA did not get a call back. R#1 whereabouts are unknown.
Due to facility closing we were unable to locate all parties involved in the complaint. Therefore we were unable to complete a full investigation. Therefore Based upon this investigation, LPA finds that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Allegation #2: Facility staff did not assist resident with hygiene care

It is alleged that Resident #1 (R1) was not receiving assistance with her hygiene and was observed with a diaper on that appeared to be on for days.

LPA Mixson attempted to contact the Licensee/Administrator at the provided contact numbers without success. Community Care Licensing (CCL) staff have attempted to make contact via phone numbers and email on file of facility without success.


On 10/22/2025 Licensing Program Analyst Sparkle Day began the follow up investigation. LPA Day observed this facility Closed on 11/16/2022. LPA Day attempted to call reporting party and did not get a response after 3 attempts. LPA Day attempted to call facility phone number and Licensee phone number and has been unable to reach anyone. LPA attempted to reach where allegedly R#1 moved to, however after 3 attempts LPA did not get a call back. R#1 whereabouts are unknown.
Due to facility closing we were unable to locate all parties involved in the complaint. Therefore we were unable to complete a full investigation. Therefore Based upon this investigation, LPA finds that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Allegation #3: Facility staff spoke inappropriately in the presence of residents

It is alleged that Licensee and Husband was observed arguing in the presence of the residents.

LPA Mixson attempted to contact the Licensee/Administrator at the provided contact numbers without success. Community Care Licensing (CCL) staff have attempted to make contact via phone numbers and email on file of facility without success. .


On10/22/2025 Licensing Program Analyst Sparkle Day began the follow up investigation. LPA Day observed this facility Closed on 11/16/2022. LPA Day attempted to call reporting party and did not get a response after
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Sparkle Day
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20221102171633
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: FOREST VIEW GUEST HOME
FACILITY NUMBER: 374601291
VISIT DATE: 10/22/2025
NARRATIVE
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3 attempts. LPA Day attempted to call facility phone number and Licensee phone number and has been
unable to reach anyone. LPA attempted to reach where allegedly R#1 moved to, however after 3 attempts LPA did not get a call back. R#1 whereabouts are unknown.
Due to facility closing we were unable to locate all parties involved in the complaint. Therefore we were unable to complete a full investigation. Therefore Based upon this investigation, LPA finds that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

A copy of this report is being mailed to the last known address: 1145 Evergreen Lane, Vista CA 92084

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Sparkle Day
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3