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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603713
Report Date: 08/04/2026
Date Signed: 08/04/2026 03:37:56 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
07/31/2023 and conducted by Evaluator Tiffany Holmes
COMPLAINT CONTROL NUMBER: 08-AS-20230731093707
FACILITY NAME:PARKVIEW MEMORY CARE AT PARADISE VILLAGEFACILITY NUMBER:
374603713
ADMINISTRATOR:AGUILAR, GEOVANNIFACILITY TYPE:
740
ADDRESS:735 ARCADIA AVENUETELEPHONE:
(619) 475-5040
CITY:NATIONAL CITYSTATE: CAZIP CODE:
91950
CAPACITY:70CENSUS: 53DATE:
08/04/2026
UNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Leah Adolfo, Health Services DirectorTIME COMPLETED:
03:47 PM
ALLEGATION(S):
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Staff hit resident
Staff yelled at resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA)Tiffany Holmes conducted an unannounced visit to close out an investigation on the above-mentioned allegations. LPA was granted entry by Front Lobbyist and then met with Leah Adolfo, Health Services Director and explained the purpose of the visit.

LPA previously conducted interviews with residents, staff, and outside sources, made observations, and obtained and reviewed pertinent records. LPA Correia conducted the initial visit on August 08, 2023 and May 24, 2024 and conducted a tour of the facility . It was alleged that the staff hit resident and the staff yelled at resident. Interviews revealed that on 7/23/23 Staff 1 (S1) was trying to change Resident 1 (R1’s) brief’s. According to interviews, R1 was resisting being changed and S1 called for assistance. S2 and S3 came to assist. Staff interviews revealed both staff observed S1 smack R1 to get them to comply. Interviews revealed that R1 was agitated and went to punch staff, that’s when S1 smacked R1 and yelled at them, “You don’t hit me” and then smacked them. Interviews revealed after S1 smacked R1 they were able to change R1’s briefs. Interviews revealed that the staff that was with S1 told management about how S1 acted.

During the course of the investigation it was revealed that the facility conducted their own internal investigation; however, they never documented the interviews conducted during the investigation. Interviews revealed shortly after S1 was allowed to return to work they resigned. Interviews also revealed that since the complaint was opened that R1 had passed away.

The Department has investigated the above-mentioned allegations and based on interviews, LPA observations, and records review, it was determined that the complaint allegations are substantiated. The allegations are valid, and preponderance of the evidence has proven that the alleged violations occurred.
Deficiencies are listed on the 9099d page

An exit interview was conducted with Leah Adolfo, Health Services Director and a copy of this report along with Licensee/Appeal Rights (LIC 9058 03/22) was provided at the conclusion of the visit.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2026
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 2
Control Number 08-AS-20230731093707
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: PARKVIEW MEMORY CARE AT PARADISE VILLAGE
FACILITY NUMBER: 374603713
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/21/2026
Section Cited
CCR
87468.1(a)(1)
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87468.1 Personal Rights of Residents in All Facilities: “(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff…” This requirement was not met, as evidenced by:
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Licensee agreed to complete an inservice regarding personal rights for all staff by the POC due date of 8/21/2026. Licensee will provide LPA Holmes a copy of the sign in sheet and training materials by email by POC due date.
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Based on records and interviews, Licensee did not treat 1 of 53 residents (R1) with dignity. This posed an immediate personal rights risk to persons in care.
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Type A
08/21/2026
Section Cited
CCR
87468.1(a)(3)
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87468.1 Personal Rights of Residents in All Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.
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Licensee agreed to complete an inservice regarding physical and verbal abuse for all staff by the POC due date of 8/21/2026. Licensee will provide LPA Holmes a copy of the sign in sheet and training materials by email by POC due date.
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This requirement was not met, as evidenced by:
Based on records and interviews, Licensee did not speak respectfully to 1 of 53 residents (R1). This posed an immediate personal rights risk to 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.
SUPERVISOR'S NAME: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2