374603539-12-19-2024-08-AS-JROO-DG98FV-20250430222923

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603539
Report Date: 12/16/2024
Date Signed: 12/19/2024 09:10:09 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/18/2021 and conducted by Evaluator Amy Domingo

COMPLAINT CONTROL NUMBER: 08-AS-20211118141358

FACILITY NAME:	HOUSE OF J 2		FACILITY NUMBER:	374603539
ADMINISTRATOR:	JOSIE DIZON		FACILITY TYPE:	735
ADDRESS:	1809 FALLBROOK OAKS COURT		TELEPHONE:	(442) 444-8362
CITY:	FALLBROOK	STATE: CA	ZIP CODE:	92028
CAPACITY:	6	CENSUS: 6	DATE:	12/16/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Josie Dizon Administrator		TIME COMPLETED:	11:20 AM

ALLEGATION(S):

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Neglect to client resulting in serious bodily injury.
Lack of supervision resulting in client on client altercation.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Amy Domingo Licensing conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced herself and disclosed the purpose of the visit to Administrator Josie Dizon.

The Department’s investigation consisted of interviews with residents, staff, outside sources, and records review. It was alleged that there was neglect to a resident resulting in serious bodily injury and lack of supervision resulting in resident on resident altercation.

Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024

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-20211118141358

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: HOUSE OF J 2	FACILITY NUMBER: 374603539
	VISIT DATE: 12/16/2024

NARRATIVE

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Continued from LIC9099

Staff 1 (S1) (See LIC811 Confidential Names list), stated that Resident 1 (R1) and Resident 2 (R2) were supervised closely when they were in the same area as they do argue. On 11/16/21, around 7:00 p.m. R1 and two other residents were watching television. R2 was talking and the other residents asked R2 to be quiet, however R2 keep talking. R1 stated that R2 was "Coco" and R2 was upset at R1 and they argued. Staff redirected R2 to go to R2's room and watch television in the room. At approximately 7:05 p.m., Staff 2 (S2) went to assist another resident in their room and S1 went to empty the trash in the garage. S1 heard screams when entering back into the house. S1 saw both R1 and R2 holding each other's heads. S1 was able to separate R1 and R2. S1 noticed R1 had blood coming from R1's lip. R1's lip looked like R2 bit a part of R1's bottom lip. S1 and Staff 3 (S3) completed an assessment of R1 and R1 was taken to the emergency room for further assessment and evaluation. Staff applied first aid which stopped the bleeding and notified supervisors who arrived within five minutes and transported the R1 to the hospital for treatment. This investigation did not reveal the staff was negligent, as it appears staff responded appropriately and took R1 to the Hospital.

Outside source 1 (OS1) was interviewed and the facility made OS1 aware of the incident. OS1 stated that there has not been any concerns regarding proper supervision of resident by staff. OS1 has no concerns regarding the facility. Outside source 2 (OS2) was interviewed and OS2 stated that the facility followed the appropriate steps to report and provide care for the resident.

The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of the evidence has not been met, therefore, this allegation is deemed unsubstantiated.

An exit interview was conducted with Josie Dizon, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 03/22).

SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024

LIC9099 (FAS) - (06/04)

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