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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603824
Report Date: 10/23/2024
Date Signed: 10/23/2024 10:29:40 AM

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
08/30/2024 and conducted by Evaluator Iby Strong
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20240830163352
FACILITY NAME:TIZON'S PRIME CARE INCFACILITY NUMBER:
374603824
ADMINISTRATOR:CALUMPONG, GRACEFACILITY TYPE:
735
ADDRESS:833 RANGEVIEW STREETTELEPHONE:
(619) 227-2010
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY:6CENSUS: 6DATE:
10/23/2024
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Caregiver Nathaniel VelascoTIME COMPLETED:
08:30 AM
ALLEGATION(S):
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Client was not treated with dignity and respect
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to deliver findings in the above-mentioned allegation. LPA identified herself and discussed the purpose of the visit with Caregiver Nathaniel Velasco. Assistant Administrator Reginal Cosico was present via telephone.

During the investigation, LPA Strong collected pertinent client records as well as facility documentation and conducted interviews. On August 30, 2024, Community Care Licensing (CCL) received a complaint alleging Staff 1 (S1) spoke to Client 1 (C1) in an abusive manner. According to C1’s Physician Report signed November 01, 2023, C1 can communicate and has no issues with confusion or depression. Interview with C1 revealed that S1 used statements towards C1 that were hurtful. C1 revealed S1 has yelled at C1 to go to their room, used the middle finger against C1 and told C1 that they didn’t like C1. Interview with outside source revealed that S1 was witnessed telling C1 “I hate you, you are so stubborn”, causing C1 to cry. Interview with Client 2 (C2) revealed that S1 has been observed yelling at C1 on multiple occasions. Interview with Administrator revealed that S1 has been terminated from employment due to reported information.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024
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-20240830163352
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: TIZON'S PRIME CARE INC
FACILITY NUMBER: 374603824
VISIT DATE: 10/23/2024
NARRATIVE
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Based on interviews a preponderance of evidence exists to support the allegation. A deficiency is being cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). An exit interview was conducted with Caregiver Nathaniel Velasco and Assistant Administrator, to whom a copy of this report, LIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024
LIC9099 (FAS) - (06/04)
Page: 2 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
08/30/2024 and conducted by Evaluator Iby Strong
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20240830163352

FACILITY NAME:TIZON'S PRIME CARE INCFACILITY NUMBER:
374603824
ADMINISTRATOR:CALUMPONG, GRACEFACILITY TYPE:
735
ADDRESS:833 RANGEVIEW STREETTELEPHONE:
(619) 227-2010
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY:6CENSUS: DATE:
10/23/2024
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Caregiver Nathaniel Velasco. Assistant Administrator Reginal Cosico was present via telephoneTIME COMPLETED:
08:30 AM
ALLEGATION(S):
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9
Staff physically abused client in care
Neglect/Lack of supervision resulted in injury
Facility staff did not provide incontinence care
Facility staff did not ensure client was free of odors
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to deliver a complaint investigation on the above allegations. LPA identified herself and discussed the purpose of the visit with Caregiver Nathaniel Velasco. Assistant Administrator Reginal Cosico was present via telephone.

On August 30, 2024, Community Care Licensing (CCL) received a complaint alleging an unknown staff physically abused Client 1 (C1), neglect/Lack of supervision resulted in injury to C1, facility staff did not provide incontinence care to C1, and facility staff did not ensure C1 was free of odors. During the investigation, LPA Strong collected pertinent client records, and conducted multiple interviews. C1’s Physician Report signed November 01, 2023, states C1 can communicate and has no issues with confusion or depression. Additionally, C1’s Individual Program Plan revealed that C1 has an unsteady gait but is independent with most self-care skills.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 08-AS-20240830163352
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: TIZON'S PRIME CARE INC
FACILITY NUMBER: 374603824
VISIT DATE: 10/23/2024
NARRATIVE
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According to allegations, C1 was observed with a large bruise on the face that may have resulted from physical abuse from staff or neglect/lack of supervision. Interview with C1 revealed that C1 had an incident in the facility bathroom where C1 lost their balance and hit self on counter resulting in bruise on the face. Interview with staff present on the date of the incident revealed that staff were unaware of the injury until the bruise appeared on C1s face. Interview with Administrator established that C1 had reported the incident to Administrator. Interview with multiple outside sources revealed that C1 has a history of unsteady gait resulting in falls. Records collected established that C1 does not require constant supervision in activities of daily living. Outside source interviews did not reveal any information to corroborate that abuse or neglect/lack of supervision resulted in C1’s bruise.

It was also alleged that staff did not provide C1 with incontinence care, leaving C1 undergarments wet while out in the community resulting in strong odors. Interview with staff revealed C1 receives assistance with incontinence care before each outing. Interviews revealed that C1 has a history of urine incontinence and facility has C1 on a schedule to provide that incontinence care. Interview with clients in care did not reveal any information to corroborate that facility does not provide incontinence care to C1 or any other client. Outside source interviews revealed that C1 has not been observed to have strong odors or lack of incontinence care from staff. Additional medical records collected revealed that C1 has been evaluated by primary care provider for incontinence related issues including lab work on August 30, 2024 and x-rays on September 17, 2024. Lastly, on September 5, 2024, LPA toured facility and did not witness any urine odors within the facility or near C1.

Based on LPA's interviews, and record reviews there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegations are unsubstantiated. An exit interview was conducted with Caregiver Nathaniel Velasco and Assistant Administrator to whom a copy of this report and appeals rights were provided to.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 08-AS-20240830163352
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: TIZON'S PRIME CARE INC
FACILITY NUMBER: 374603824
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/06/2024
Section Cited
CCR
80072(a)(1)
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80072 Personal Rights (a)…each client shall have personal rights which include, ….(1)To be accorded dignity in his/her personal relationships with staff…This requirement has not been met as in evidence:
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Licensee agrees to train staff for client personal rights, S1 has been terminated.
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Based on interviews the licensee did not not accords clients in care dignity in their personal relationships with staff in one of six persons in care (C1) which posed a potential 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.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5