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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603759
Report Date: 01/21/2025
Date Signed: 01/21/2025 10:41:42 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/26/2021 and conducted by Evaluator Tiffany Holmes
COMPLAINT CONTROL NUMBER: 08-AS-20210326152046
FACILITY NAME:DAYBREAK VILLA EASTFACILITY NUMBER:
374603759
ADMINISTRATOR:CORPUZ, ROLANDOFACILITY TYPE:
740
ADDRESS:1682 DAYBREAK PLACETELEPHONE:
(760) 781-1079
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY:6CENSUS: 4DATE:
01/21/2025
UNANNOUNCEDTIME BEGAN:
09:28 AM
MET WITH:Avelino Acedo, CaregiverTIME COMPLETED:
10:49 AM
ALLEGATION(S):
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Resident wandered away from the facility due to lack of supervision
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA)Tiffany Holmes conducted an unannounced complaint visit to the facility to deliver findings on the above-mentioned allegation. LPA gained access to the facility, identified herself, and met with Avelino Acedo, Caregiver to discuss the purpose of the visit. LPA’s visit consisted of delivering the finding on the above-mentioned allegation.

LPA conducted a physical inspection of the facility, collected relevant records, and conducted interviews with residents, facility staff, and outside sources. It was alleged that Resident 1 (R1) wandered away from the facility due to lack of supervision. Interviews revealed on March. 26, 2021 (R1) Awol'd and wandered away from the facility. Interviews revealed R1 was away from the facility for about 1-2 hours. Interviews revealed R1 was away between the hours of 1:00 pm - 230pm.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Tiffany HolmesTELEPHONE: (619) 481-0843
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025
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-20210326152046
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: DAYBREAK VILLA EAST
FACILITY NUMBER: 374603759
VISIT DATE: 01/21/2025
NARRATIVE
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Interviews revealed S1 admitted to leaving the resident unsupervised. Interviews also revealed that S1 was very busy cooking and did not notice the resident leaving the facility. Interviews revealed the alarms were not on at the facility so they didn't hear when the resident opened the door to leave. Interviews revealed there was another staff that was at the facility also but was working with another resident while S1 was in the kitchen cooking and feeding the residents. Interviews revealed the police came to the door and asked staff if the resident was a resident to the facility and S1 told the police yes. Interviews revealed that S1 brought the resident back in and notified the administrator.

Based on the evidence obtained from interviews, the complaint allegation is found to be substantiated; as the preponderance of evidence proves the alleged violation occurred.

An exit interview was conducted with Avelino Acedo, Caregiver and a copy of this report along with Licensee/Appeal Rights (LIC 9058 03/22) was provided at the conclusion of the visit.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Tiffany HolmesTELEPHONE: (619) 481-0843
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20210326152046
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: DAYBREAK VILLA EAST
FACILITY NUMBER: 374603759
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/06/2025
Section Cited
CCR
87464(f)(1)(c)
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87464 Basic Services (f)(1)(c)
Basic Services. Care and supervision as defined in section 87101(c)(3) and Health and Safety Code section 1569.2(c). “Care and Supervision” means the facility assumes responsibility for…on going assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered.

This requirement is not met as evidenced by:
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Licensee will provide training to staff regarding resident supervision and recognizing signs of wandering by an outside source. Staff will also check files to see if any residents do wander. Licensee will start a monthly maintence log regarding door alarms POC due date of 02/06/2025
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Based on record review and interviews, the licensee did not provide basic services for 1 out of 4 residents, by not providing the required supervision which poses an immediate health and safety risk to residents 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: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Tiffany HolmesTELEPHONE: (619) 481-0843
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3