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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374602092
Report Date: 07/08/2025
Date Signed: 07/08/2025 04:03:28 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
07/01/2025 and conducted by Evaluator Ramon Serrano
COMPLAINT CONTROL NUMBER: 08-AS-20250701091143
FACILITY NAME:FRIENDLY HOME IIFACILITY NUMBER:
374602092
ADMINISTRATOR:RONDA GAMBLE-HOLMESFACILITY TYPE:
735
ADDRESS:504 RITCHEY STTELEPHONE:
(619) 263-2127
CITY:SAN DIEGOSTATE: CAZIP CODE:
92114
CAPACITY:22CENSUS: 15DATE:
07/08/2025
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Ethan Vibal and Bienvenida Hilario TIME COMPLETED:
03:58 PM
ALLEGATION(S):
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Staff did not address a client's change in medical condition
Staff did not prevent a client from self harm
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced complaint visit to investigate and deliver findings on the above allegations. LPA met with Assistant Administrator Ethan Vibal and we discussed the purpose of the visit and elements of the complaint. LPA conducted an exit interview with Caregiver Bienvenida Hilario.

Community Care Licensing (CCL) has investigated the above allegations. The investigation consisted of records review, interviews with facility staff, clients and outside sources.

It was alleged that facility staff did not address Client 1(C1's) change in medical condition. It was also alleged that staff did not prevent C1 from self harm. It was reported that on June 29, 2025 emergency services arrived at the facility after they were called by C1. It was reported that C1's chief complaint was suicidal ideations for the past three weeks. It was noted that C1 had a fever and was very tired. It was reported that C1 had not eaten or slept for three weeks.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025
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 4
Control Number 08-AS-20250701091143
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: FRIENDLY HOME II
FACILITY NUMBER: 374602092
VISIT DATE: 07/08/2025
NARRATIVE
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LPA reviewed C1's Physician's report dated December 10, 2013 which had no diagnosis listed. LPA reviewed C1's needs and service plan dated January 1, 2024. C1's diagnosis included; schizophrenia, mood disorder and Diabetes (controlled with diet and medication) LPA reviewed C1's medication administration report (MAR's) for the months of June and July 2025. MAR's indicated that C1 did not take C1's medications on the following dates; June 10-11, June 17-18, June 24-25. Facility staff were unable to determine if the missed medications were due to client refusal or due to client being away from the facility.

LPA interviewed C1 at the facility. C1 spoke to LPA hunched over. C1 appeared weak and sickly. C1 stated that prior to calling 911 C1 had not eaten for 3-4 months. C1 stated that C1 does not like "chicken and rice" and that is what they serve every day. C1 stated that C1 purchases their own snacks but C1 has not had much of an appetite. C1 stated that they have told all of the staff and although they stated they would change the menu, it has remained the same. C1 stated that C1 has only missed taking their medications "a couple of times" a month. C1 stated that they had suicidal ideations for a week, on and off, prior to going to the hospital. C1 stated that C1 returned from the hospital six days ago and and has not eaten, with the exception of a bowl of cereal which C1 could not finish. C1 stated that they have the following medical conditions; diabetes, high cholesterol and high blood pressure. C1 stated that C1 has not checked their blood sugar and does not know what it currently is.

LPA interviewed Client 2 (C2) at the facility. C2 stated that C1 has not been eating for a month. C2 stated that if C1 does not like the food they will not eat it. C2 stated that facility staff are aware that C1 has not been eating. C2 stated that staff have not helped C1. C2 stated that C2 purchased several snacks for C1 but C1 has not touched them. C2 stated that the facility serves boiled chicken and rice daily. C2 stated that when emergency services arrived at the facility for C1, C1 was weak and was taken to the hospital. Client 3 (C3) and Client 4 (C4) corroborated C1's statement that the facility serves chicken and rice on a daily basis.

LPA interviewed Outside Source (OS) who stated that on the date that emergency services arrived at the facility, EMT waited 5-10 minutes before entering the gated facility since their were no staff members present. OS stated that EMT's entered the facility after C1 "flagged them down" and told them to enter the facility. OS stated that C1 advised the EMT that C1 had resided at the facility for 10-15 years and has eaten the same two meals for their entire stay. C1 stated that C1 had suicidal ideations and had not eaten or slept for three weeks. C1 was taken to the hospital with a fever over 100 degrees.
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 08-AS-20250701091143
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: FRIENDLY HOME II
FACILITY NUMBER: 374602092
VISIT DATE: 07/08/2025
NARRATIVE
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LPA interviewed Staff 1 (S1) who stated that C1 was doing well up until last week. S1 stated that C1 does not like "chicken and rice" but he is certain that the afternoon staff provides C1 with other options. S1 was not able to advise what other food options C1 is provided. S1 had no knowledge of C1's suicidal ideations and stated that they have spoken to a psychiatrist regarding C1. S1 stated that it seems C1's medical condition has changed. S1 explained that C1's mood has changed and C1 is always laying in bed now. S1 stated that they are now going to "lean towards" providing C1 with their food preference

LPA interviewed Administrator (ADM) who stated that C1 recently returned to live at the facility after a brief stay at an ILF. ADM stated that C1 started acting strange in June. ADM stated that he was with C1 prior to C1 calling 911 and he did not understand why C1 did not ask him to take him to the hospital. ADM stated that C1 has not been eating. ADM stated that he has offered C1 several other options including pork or beef but C1 has refused all food options.

Based upon the foregoing, the above listed allegations are substantiated. This finding means that the preponderance of the evidence standard has been met and the allegations are valid. Deficiencies are cited in accordance with California Code of Regulations, Title 22 and are noted on the attached LIC 9099-D.

An exit interview was conducted with Caregiver Bienvenida Hilario and a copy of this report and Licensee/Appeal Rights (LIC9058, 3/22) were provided to Bienvenida Hilario whose signature below confirms receipt of documents.
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 08-AS-20250701091143
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: FRIENDLY HOME II
FACILITY NUMBER: 374602092
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/19/2025
Section Cited
CCR
80078(a)
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(a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement was not met as evidenced by:
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Licensee stated that they will conduct a training which addresses both the clients needs and service plans and meeting the clients medical needs. Licensee will provide a signed training log by POC due date, 11/19/2025.

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Based on observation and interview, facility staff did not provide care and supervision to meet the needs of one client (C1) resulting in hospitalization. This posed an immediate health, safety and personal rights risk to 1 of 15 clients in care.
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“This is an amended version of the original report created on 07/08/2025.”
Type B
12/03/2025
Section Cited
CCR
85075.4(c)
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85075.4 Observation of the Client (c) The licensee shall bring observed changes, including… deterioration of health condition, to the attention of the client's physician and authorized representative… This requirement was not met as evidenced by:
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Licensee stated that they will conduct a training which addresses meeting individual client needs and early signs of illness and need for professional assistance. Licensee will provide a signed training log by POC due date, 12/03/2025.
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Based on observation and interview, facility staff did not report the observed deterioration of one client’s health (C1) to their doctor and/or authorized representative. This posed a potential health, safety and personal rights risk to 1 of 15 client’s in care.
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“This is an amended version of the original report created on 07/08/2025.”
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: Robyn Clark
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4