374602972-2-10-2026-08-AS-APAO-DRGR46-20260220114102

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374602972
Report Date: 02/10/2026
Date Signed: 02/10/2026 01:58:21 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
12/16/2024 and conducted by Evaluator Ramon Serrano

COMPLAINT CONTROL NUMBER: 08-AS-20241216092749

FACILITY NAME:	PLAZA VILLAGE SENIOR LIVING		FACILITY NUMBER:	374602972
ADMINISTRATOR:	SHETLER, MARIA		FACILITY TYPE:	740
ADDRESS:	950 L AVE		TELEPHONE:	(619) 474-4844
CITY:	NATIONAL CITY	STATE: CA	ZIP CODE:	91950
CAPACITY:	85	CENSUS: 57	DATE:	02/10/2026
		UNANNOUNCED	TIME BEGAN:	08:55 AM
MET WITH:	Megan Amy Moore		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Lack of supervision resulted in resident eloping from facility
Staff did not report missing resident in a timely manner
Residents were locked out of the facility

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced complaint visit to deliver complaint investigation findings. LPA introduced himself and stated the purpose of the visit with Executive Director Megan Amy Moore.

On December 16, 2024, the Department received a complaint alleging that lack of supervision resulted in a resident leaving the facility without permission, staff did not report the missing resident in a timely manner, and residents were locked out of the facility. Licensing Program Analyst (LPA) conducted an investigation that included interviews with staff, residents, pervious and current Executive Directors (ED), as well as a review of facility records such as physician reports, care plans, and sign-in/sign-out sheets.It was reported that Resident 1 (R1) left the facility alone on December 15, 2024, around 2:00 PM and did not return. R1 was believed to require supervision when leaving the facility. LPA reviewed R1’s physician report dated June 21, 2023, and their care plan dated March 29, 2024. Both documents show that R1 was independent with all activities of daily living except for medication assistance.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2026

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 08-AS-20241216092749

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: PLAZA VILLAGE SENIOR LIVING	FACILITY NUMBER: 374602972
	VISIT DATE: 02/10/2026

NARRATIVE

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R1 was ambulatory, able to communicate needs, and had mild cognitive impairment. Both documents indicate that R1 could leave the facility unassisted. Staff interviews confirmed that R1 regularly took walks outside the facility and signed themselves out daily. The sign-in/sign-out sheet shows R1 signed out twice on December 15, 2024. R1 first signed out at 9:06AM and signed back in at 9:38am. R1 then signed out at 1:27PM and did not sign back in. Both destinations were listed as "square walk clockwise."

The complaint also alleged that staff did not report R1 missing in a timely manner. LPA learned that R1 often left for walks and usually returned by evening. ED stated they called R1’s responsible party (RP) around 8:00 to 9:00 PM, which is the usual time RP brings R1 back. ED could not leave a voicemail because RP’s mailbox was full. ED also tried calling R1’s cell phone, but voicemail was not set up. RP called ED at 1:00 AM and confirmed R1 was not with them. Facility staff immediately called 911 after speaking with RP.

The third allegation stated that residents were locked out of the facility. Law enforcement found Resident 2 (R2) outside during their investigation. R2 told LPA that they were near the parking garage when law enforcement arrived and could have knocked on the door to be let in. R2 was new to the facility and did not remember the access code for the locked door. Facility confirmed residents are given an access code for entry outside public hours. R2’s physician report dated October 17, 2024, shows R2 is independent and can leave unassisted.

Based on all the evidence, the allegations are not supported. R1’s care plan and doctor’s report both show that R1 was allowed to leave the facility alone and often took daily walks. While the physician's report mentioned “needs supervision,” it also stated R1 could leave unassisted, which is contradictory. The facility called law enforcement as soon as they confirmed with R1’s responsible party that R1 was not with them. R2 is fully independent and was not locked out of the facility.

Based on interviews, record reviews, and observations, all allegations are unsubstantiated. This finding means that the preponderance of the evidence standard has not been met and the allegations are unsubstantiated.

An exit interview was conducted with Megan Amy Moore. A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to Megan Amy Moore whose signature below verifies receipt of these rights.

SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2026

LIC9099 (FAS) - (06/04)

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