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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603617
Report Date: 05/30/2025
Date Signed: 05/30/2025 03:41:04 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
09/15/2023 and conducted by Evaluator Nacole Patterson
COMPLAINT CONTROL NUMBER: 08-AS-20230915091556
FACILITY NAME:TORREY PINES SENIOR LIVINGFACILITY NUMBER:
374603617
ADMINISTRATOR:MCDONALD, JASONFACILITY TYPE:
741
ADDRESS:13101 HARTFIELD AVETELEPHONE:
(858) 259-2222
CITY:SAN DIEGOSTATE: CAZIP CODE:
92130
CAPACITY:125CENSUS: 0DATE:
05/30/2025
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Facility Closed - Report Mailed to Last Known Licensee Address via Certified MailTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Neglect resulting in serious bodily injury.
INVESTIGATION FINDINGS:
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The following determination of findings have been made by Licensing Program Analyst (LPA) Nacole Patterson regarding the above allegation. The facility closed on 03/29/2024 due to a change of ownership, and this report was mailed to the last known address on record for the former licensee regarding the findings.

On 09/15/2023 the allegation, "Neglect resulting in serious bodily injury" was made against the Licensee after Resident 1 (R1) sustained a pelvic fracture from a fall. The Department’s investigation consisted of unannounced facility visits, review of facility and outside source records, interviews with facility staff, residents, and outside sources. Five (5) relevant staff members were interviewed during the investigation. Staff interviews were inconsistent regarding whether staff conducted the required 2-hour status/toileting check for R1, per their care plan, before the fall occurred.

(Continued on LIC9099 p.2)
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Nacole Patterson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
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 5
Control Number 08-AS-20230915091556
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: TORREY PINES SENIOR LIVING
FACILITY NUMBER: 374603617
VISIT DATE: 05/30/2025
NARRATIVE
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(Continued from LIC9099 p.1)

Interviews revealed that Staff 2 (S2) documented that they conducted the required toileting check for R1 at 9:00pm on the day in question, however R1 was found in their bathroom at approximately 11:00pm due to an unwitnessed fall from trying to use the restroom without staff assistance.

R1 informed during interview that during the incident they had attempted to use the bathroom on their own by transferring themselves from their wheelchair to the toilet. R1 attempted to stand but fell, hitting their head on the door frame. R1 could not recall if a staff member checked on them at the 9:00pm required check.

An outside source familiar with R1's care was interviewed, revealing that additional costs were paid by R1's family to have staff check on R1 every two hours, and the protocol was included in R1's care plan. The outside source informed that a video recording of R1's room during the timeframe of concern revealed that staff did not conduct the required 2-hour status/toileting check for R1, prior to the fall.

Records review revealed that R1's care plan required daily toileting checks and/or assistance at the following times: 1:00am, 5:00am, 7:00am, 9:00am, 11:00am, 1:00pm, 3:00pm, 5:00pm, 7:00pm, and 9:00pm. Care history records for R1 showed that S2 signed off on R1's care history log, indicating that they had assisted R1 with toileting at 9:00pm on the day in question. Review of video footage revealed that no staff member entered R1's room at this time. The video footage showed that staff entered R1's room at 6:57pm, and the next staff entrance into R1's room was at 11:12pm, in response to R1's fall. Records additionally showed that five (5) days prior to the incident, a meeting occurred between R1's family and the facility regarding staff not adhering to the toileting schedule for R1. The family was given a credit on their monthly bill by the facility due to the service not being provided per the schedule, and the facility informed that an in-service training would be done with staff regarding the issue.

Attempts were made to interview S2, who indicated that they had conducted a toileting check on R1 at 9:00pm on the day in question. Interview attempts were unsuccessful due to an outside individual who identified themselves as S2's representative obstructing the interview. The interview attempt did not result in any additional information relevant to the incident in question.

Based on relevant interviews and records review, the preponderance of evidence has been met that alleged violation occurred and is therefore substantiated. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). An immediate $500 civil penalty was assessed. Per Health and Safety Code Section 1569.49, an additional civil penalty is under review by the Program Administrator of the Community Care Licensing Division. A copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were mailed to the last known address on file for the facility.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Nacole Patterson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 08-AS-20230915091556
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: TORREY PINES SENIOR LIVING
FACILITY NUMBER: 374603617
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/06/2024
Section Cited
CCR
87468.2(a)(4)
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Additional Personal Rights of Residents in Privately Operated Facilities: 87468.2(a)(4) …residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs. This requirement was not
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Facility closed on 3/29/2024.
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met, as evidenced by:

Based on records and interviews, Licensee did not provide supervision and services necessary to meet the need of Resident 1 (R1). This posed an immediate health and safety risk to 1 of 96 persons in care.
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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: Lizzette Tellez
LICENSING EVALUATOR NAME: Nacole Patterson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
09/15/2023 and conducted by Evaluator Nacole Patterson
COMPLAINT CONTROL NUMBER: 08-AS-20230915091556

FACILITY NAME:TORREY PINES SENIOR LIVINGFACILITY NUMBER:
374603617
ADMINISTRATOR:MCDONALD, JASONFACILITY TYPE:
741
ADDRESS:13101 HARTFIELD AVETELEPHONE:
(858) 259-2222
CITY:SAN DIEGOSTATE: CAZIP CODE:
92130
CAPACITY:125CENSUS: 0DATE:
05/30/2025
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Facility Closed - Report Mailed to Last Known Licensee Address via Certified MailTIME COMPLETED:
03:45 PM
ALLEGATION(S):
1
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9
Neglect resulting in delayed medical care.
INVESTIGATION FINDINGS:
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12
13
The following determination of findings have been made by Licensing Program Analyst (LPA) Nacole Patterson regarding the above allegation. The facility closed on 03/29/2024 due to a change of ownership, and this report was mailed to the last known address on record for the former licensee regarding the findings.

On 09/15/2023 the allegation, "Neglect resulting in delayed medical care" was made against the Licensee after a resident suffered a fall. The Department’s investigation consisted of unannounced facility visits, review of facility and outside source records, interviews with facility staff, residents, and outside sources. Five (5) relevant staff were interviewed during the investigation. Staff interviews confirmed that Resident 1 (R1) suffered a fall in their bathroom after attempting to use the restroom without staff assistance. Staff interviews revealed that R1 called out for help after the fall and staff responded right away, initiating emergency response and staying with R1 until the paramedics arrived. Records review supported staff statements, showing that two staff assisted R1 by calling 911 and following protocols until the paramedics arrived for transport. (Continued on LIC9099 p.2)
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Nacole Patterson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 08-AS-20230915091556
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: TORREY PINES SENIOR LIVING
FACILITY NUMBER: 374603617
VISIT DATE: 05/30/2025
NARRATIVE
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(Continued from LIC9099 p.1)

An outside source familiar with R1's care corroborated staff statements, informing that video footage showed staff responding to R1's call out for help. The outside source informed that staff initiated paramedic response and contacted R1's responsible party. Review of charting notes and video footage corroborated staff statements, showing that staff responded immediately to R1's fall due to R1 calling out for help, and initiated emergency services for hospital transport.

Based on interviews, and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. A copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were mailed to the last known address on file for the facility.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Nacole Patterson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5