374602984-9-26-2025-08-AS-BCHN-DM2USG-20251001155020

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374602984
Report Date: 09/26/2025
Date Signed: 09/26/2025 02:26:59 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
10/26/2023 and conducted by Evaluator Grace Donato

PUBLIC

COMPLAINT CONTROL NUMBER: 08-AS-20231026170448

FACILITY NAME:	HOME OF GUIDING HANDS-CALDERA		FACILITY NUMBER:	374602984
ADMINISTRATOR:	RENE DOEHRER		FACILITY TYPE:	735
ADDRESS:	9915 VIA RITA		TELEPHONE:	(619) 596-2067
CITY:	SANTEE	STATE: CA	ZIP CODE:	92071
CAPACITY:	4	CENSUS:	DATE:	09/26/2025
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Rene Doehrer		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Questionable death
Staff made false statements regarding death
Staff did not provide adequate food to residents

INVESTIGATION FINDINGS:

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On 9/26/2025, LPA Grace Donato conducted a telephone interview to the facility to deliver findings. LPA spoke with Administrator Rene Doehrer and explained the purpose of the call.

Regarding the allegation of questionable death, Reporting Party (RP) stated that it was reported to RP that the resident (R1) had died.

During the course of the investigation, staff members were interviewed, and records were reviewed.

The Event Chronology from local Sheriff’s Department (SD) shows an emergency call was made on 10/13/2022 at 0423 hours. The Body Worn Camera footage from the local SD shows CPR was initiated by deputies on R1 near the bathroom in the hallway. Paramedics arrived and moved the client to the living room floor where they continued life-saving measures. S1 checked on R1 a few minutes after 0400 hours in R1s room and asked if R1 was okay, but R1 remained quiet. S1 was then in the kitchen when R1 walked to S1 and was struggling with his/her breathing. S1 is heard saying R1 was saying “ahh, ahh, ahh,” and S1 attempted to take something out of R1s mouth before calling 9-1-1.

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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2025

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-20231026170448

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: HOME OF GUIDING HANDS-CALDERA	FACILITY NUMBER: 374602984
	VISIT DATE: 09/26/2025

NARRATIVE

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The local Regional Center reported that there were no Special Incident Reports related to R1 choking. Interviews for the staff that worked on 10/12/2022 during the PM Shift, did acknowledge barbecue ribs were served for dinner and that R1 did enjoy eating ribs. All staff interviewed reported no unusual behaviors that evening. R1 would get up in the middle of the night, but usually only to use the bathroom or get a glass of water from the kitchen. S3 stated at nighttime “R1 wasn’t the type to take food in general and look for something to take.” S1 shared that S1 did not sleep during the shift and the only time R1 left the room that evening was when S1 got R1s attention when S1 was in the kitchen. S1 did not see R1 obtain food items from the refrigerator.

R1 passed away at the hospital. R1 was described as a well-developed and well-nourished individual, and R1s upper and lower teeth were intact. There was no evidence of external injury, and R1s cause of death was determined to be an accident.

Based on interviews conducted and a review of pertinent records, the facility made efforts to address R1s productive cough with eating and drinking as staff took R1 for a follow-up with the doctor (DR) on 09/06/2022, and the subsequent Swallow Evaluation was performed on 10/03/2022. There were no instructions for facility staff for R1 to have nothing by mouth as DR was not made aware of the Swallow Evaluation results until 10/13/2022.

For the allegation of Staff made false statements regarding death, RP was told at different times by staff (names unknown) that R1 went to the kitchen for water, R1 looked strange, and collapsed. Another version is that R1 went to restroom and collapsed. A different version was that R1 was standing against the wall and staff began CPR on R1 while standing, and the last version was that R1 came to and walked outside with paramedics to the ambulance.

F1 did acknowledge the information S4 was providing, was relayed to S4 by the facility staff working on 10/13/2022. The last version is being told by S4 that R1 choked on water and died.

In the departments interview with S4, it was stated S4 has spoken to F1 in the past, but not about R1s specific cause of death. S4 contacted F1 on the morning of R1s death to let F1 know about the incident. S4 acknowledged R1 got up to get water and staff followed R1 to the bathroom as that was what was reported to S4 by staff.

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SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2025

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20231026170448

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: HOME OF GUIDING HANDS-CALDERA	FACILITY NUMBER: 374602984
	VISIT DATE: 09/26/2025

NARRATIVE

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A Body Worn Camera (BWC) footage was provided. S1 is seen in the footage, but S1 did not remain in the immediate vicinity of the living room the entire time while paramedics were performing life saving measures. Although S1 reported the client appeared to be choking, it is reasonable to determine S1 was not aware a piece of meat was found as mentioned by paramedics while at the facility as S1 was tending to a client and responding to questions from deputies.

Regarding the allegation of Staff did not provide adequate food to residents, RP stated that RP’s other family member (F2) who lives out of state would speak to R1 on a weekly basis and R1 would tell F2 that he/she was starving.

Based on the facility’s last comprehensive annual inspection which was conducted, May 28, 2025. During the visit the facility tour LPA observed a 2-day supply of perishable food and 7-day supply of non-perishable food. Additionally, Annual inspections and other visits including Case Management and Complaint Investigations, dating back to facility Licensure in May of 2010, revealed no observations or allegations regarding inadequate food at the facility. An interview with the administrator stated food is purchased once a week based on the monthly meal menu provided by a Registered Dietician.

Based on interviews, records review and observations, the department has determined that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Report is reviewed and a copy is provided.

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SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2025

LIC9099 (FAS) - (06/04)

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