374603719-8-6-2026-08-AS-THOS-DWPSH8-20260806135306

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603719
Report Date: 08/06/2026
Date Signed: 08/06/2026 01:53:19 PM

Document Has Been Signed on 08/06/2026 01:53 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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

FACILITY NAME:	EUBANK RANCH		FACILITY NUMBER:	374603719
ADMINISTRATOR/ DIRECTOR:	DE LA ROSA, ANETA		FACILITY TYPE:	735
ADDRESS:	9978 EUBANK LANE		TELEPHONE:	(619) 804-1568
CITY:	SPRING VALLEY	STATE: CA	ZIP CODE:	91977
CAPACITY: 6		CENSUS: 5	DATE:	08/06/2026
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:35 PM
MET WITH:	Rob Arrington, DSP & Analicia Tavarez, House Manager.		TIME VISIT/ INSPECTION COMPLETED:	02:02 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced Case Management Visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Rob Arrington, DSP. Analicia Tavarez, House Manager arrived during the visit. During the investigation on the questionable death of Client 1 (C1). Interviews revealed that C1 choked on food at the facility on 08/07/2025 and passed away at the hospital on 08/12/2025, due to cardiac issues. [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] According to C1’s physician’s report from 11/26/2024, C1 had bilateral blindness, developmental-delay, and needed staff help with feeding/eating. However, C1’s physician had not prescribed them a special diet or modified texture of food or drink. Interviews revealed C1 did not have a documented history/risk of choking on food. C1s Individual Program Plan and Annual Behavior Assessment corroborated these points. On 08/07/2025, interviews revealed that the Direct Support Professional (DSP) was the only staff member on duty during the incident. DSP has current First Aid Training. Interviews and surveillance footage revealed during breakfast on 08/07/2025, C1 was seated at the facility’s dining room table with DSP, and C1 was not left alone/unattended. Interviews revealed when C1 began to choke on food, DSP immediately observed this and took life-saving measures. Interviews revealed that DSP is seen contacting emergency services who later arrive at the facility, and took over life-saving measures.

Simon Jacob
Tiffany Holmes
	DATE: 08/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: EUBANK RANCH	FACILITY NUMBER: 374603719
	VISIT DATE: 08/06/2026

NARRATIVE

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According to hospital records and medical examiner (ME)/coroner records: Responding Emergency Medical Transport (EMT) personnel reported C1s airway was “completely obstructed…with eggs and potatoes,” which would break “off upon attempt to remove with Magill Forceps” and laryngoscope. Despite “excessive attempts to clear airway,” these professionals were “unable to provide adequate ventilation's due to resistance and obstruction present…” C1 was transported to the Hospital’s Emergency Department, where they were ventilated. Although a heartbeat/pulse was subsequently restored, a computed tomography (CT) scan showed that C1 had by then suffered “anoxic brain injury;” no other physical injury was observed. Interviews revealed that C1s health “steadily declined” until they progressed to “brain death” at 1814 hours on 08/12/2025. The San Diego Sheriff’s Office Computer Aided Dispatch (CAD) Report confirmed that their deputies found “no suspicious circumstances…on scene.” C1s Certificate of Death, corroborated by the ME/coroner’s report, determined the cause of death was “asphyxia due to choking on food” and the manner of death was “accident.” Based on the totality of the circumstances, there is not a preponderance of evidence proving Licensee neglect or lack of care and supervision for C1 on 08/07/2025, contributed to their subsequent death on 08/12/2025.

The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. The allegation is Unsubstantiated.

An exit interview was conducted with Analicia Tavarez, House Manager to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Tiffany Holmes
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2026

LIC809 (FAS) - (06/04)

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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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