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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603590
Report Date: 05/02/2025
Date Signed: 05/04/2025 07:48:28 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
04/17/2025 and conducted by Evaluator Natasha Persaud
COMPLAINT CONTROL NUMBER: 08-AS-20250417163533
FACILITY NAME:MIRA MESA ADULT RESIDENTIAL CARE HOMEFACILITY NUMBER:
374603590
ADMINISTRATOR:BENCY JIMENEZFACILITY TYPE:
735
ADDRESS:8933 BOGATA CIRCLETELEPHONE:
(858) 564-8358
CITY:SAN DIEGOSTATE: CAZIP CODE:
92126
CAPACITY:6CENSUS: 6DATE:
05/02/2025
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Staff, Lorna RosalesTIME COMPLETED:
02:35 PM
ALLEGATION(S):
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Staff hit a client
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit to conclude the complaint investigation regarding the above-mentioned allegation. LPA was greeted by and met with Staff, Lorna Rosales. LPA discussed the plan of correction via telephone with Administrator, Bency Jimenez.

During the course of the investigation, the facility was toured, records reviewed, and interviews conducted with staff, clients, and outside sources which included medical professionals, family members, and agencies familiar with the facility. It was alleged that staff hit client. It was specifically reported that on April 15, 2025, Staff #1 (S1) slapped Client #1 (C1) on the abdominal region and yelled at them to get back in bed. C1’s Physician’s Report dated April 1, 2024, indicated that they had an Intellectual Disability. Their Individual Service Plan dated June 13, 2024, completed by a Licensed Psychologist indicated C1 had “challenging behaviors” including outbursts, physical aggression and self-abuse. Continued on an LIC 9099C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2025
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 08-AS-20250417163533
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: MIRA MESA ADULT RESIDENTIAL CARE HOME
FACILITY NUMBER: 374603590
VISIT DATE: 05/02/2025
NARRATIVE
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On April 23, 2025, the Department interviewed all clients in care (C1-C6), however they were not oriented or able to provide relevant details pertaining to the incident. Three staff members were also interviewed (S2-S4), all who denied that S1 would have slapped a client. On April 23, 2025, the Department interviewed the facility Administrator (ADM) who explained that staff don’t hit or yell at clients. ADM further explained that staff do have to elevate their voice at times to show authority and for the client to hear them. S1 denied hitting C1 and stated they have never hit a client. However, interviews with Outside Sources (OS1 and OS2) who were confirmed present at the time of the incident, corroborated that S1 raised their hand and hit C1 as the client was exiting their bedroom. OS1 reported they witnessed C1 leave their bed and walk into another room in the home. As they walked past S1, S1 raised their hand and hit C1. An additional witness (OS2) revealed they heard the slap and turned around. OS2 explained that they perceived S1 was upset that C1 left their room.

Based on interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 1 is being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Staff, Lorna Rosales whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Client #1 and Staff #1]

SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20250417163533
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: MIRA MESA ADULT RESIDENTIAL CARE HOME
FACILITY NUMBER: 374603590
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/03/2025
Section Cited
CCR
80065(l)
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Personnel Requirements. Personnel shall provide for the care and safety of persons without physical or verbal abuse, exploitation or prejudice. This requirement is not met as evidenced by:
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Administrator stated all staff, including S1 will be trained on Abuse against disabled adults. Training will be scheduled by POC due date and proof of completed training will be submitted within 2 weeks.

Administrator also stated S1 will be placed on
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Based on interviews, the licensee did not ensure C1 was free from physical abuse for 1 out of 6 clients [C1], which poses an immediate health, safety, and personal rights risk to clients in care.
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suspension until the facility concludes their own investigation.
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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: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3