374603699-1-21-2021-08-AS-RHEK-BXTCTF-20210201011239

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603699
Report Date: 01/21/2021
Date Signed: 01/21/2021 09:31:36 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
04/01/2020 and conducted by Evaluator Raymond Wu

COMPLAINT CONTROL NUMBER: 08-AS-20200401164114

FACILITY NAME:	SAPPHIRE LAKE SAN MARCOS		FACILITY NUMBER:	374603699
ADMINISTRATOR:	MATIC, VICTORIA		FACILITY TYPE:	740
ADDRESS:	839 LA TIERRA DRIVE		TELEPHONE:	(760) 471-1157
CITY:	SAN MARCOS	STATE: CA	ZIP CODE:	92078
CAPACITY:	6	CENSUS: 6	DATE:	01/21/2021
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Administrator Victoria Matic		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Personal Rights

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Raymond Wu conducted an unannounced virtual complaint visit due to COVID-19 with Administrator, Victoria Matic, to deliver findings for the above allegation. LPA identified himself and stated the purpose of the visit. As part of the investigation, the Department conducted interviews with relevant parties, reviewed documents, and conducted interviews with third-party sources.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Hedgecock	TELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Raymond Wu	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 01/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2021

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-20200401164114

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: SAPPHIRE LAKE SAN MARCOS	FACILITY NUMBER: 374603699
	VISIT DATE: 01/21/2021

NARRATIVE

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It was alleged that in an isolated incident in April of 2020, a staff member had verbally threatened a resident in care due to a private dispute. Included in the original report were allegations of the staff member threatening to physically assault the resident and withhold food from the resident. State regulations mandate that residents in care are to be free from all forms of abuse, intimidation, and actions of a punitive nature. In interviews conducted regarding the incident, witnesses stated that although a discussion was had regarding a private grievance, there were no verbal threats or acts of aggression committed by the staff member. Furthermore, all relevant individuals confirmed that food was never withheld from the resident in care and no acts of physical aggression were committed. In interviews conducted with outside sources, sources revealed that they had not ever seen or heard of staff at the facility verbally threatening or withholding food from residents in care.

Based on interviews conducted and records reviewed, there is not a preponderance of evidence to prove the alleged violation occurred. Therefore, the allegation is unsubstantiated. An exit interview was conducted and a copy of this report, along with Licensee’s Rights (LIC 9058 01/16), was provided to the Licensee via electronic mail. An electronic read receipt was requested to be sent by the Licensee.

SUPERVISOR'S NAME: Rebecca Hedgecock	TELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Raymond Wu	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 01/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2021

LIC9099 (FAS) - (06/04)

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