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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603824
Report Date: 06/09/2025
Date Signed: 06/09/2025 03:50:40 PM

Substantiated


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
04/25/2025 and conducted by Evaluator Dang Nguyen
COMPLAINT CONTROL NUMBER: 08-AS-20250425161712
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:
06/09/2025
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Licensee/Administrator Grace Cosico and Manager Reginald CosicoTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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-Licensee did not give client medication as prescribed.
-Licensee did not store client's medication in its originally received container.
-Licensee’s staff did not display skill/knowledge regarding medication assistance.
-Licensee’s staff did not meet reporting requirements regarding incident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced subsequent visit to deliver findings regarding the above prior complaint allegations. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Rodolfo Laforteza. LPA also met and discussed the purpose of the visit with Licensee/Administrator Grace Cosico and Manager Reginald Cosico, who arrived shortly after.

The Complainant alleged that Licensee did not give Client #1 (C1) their medication as prescribed, that Licensee did not store C1’s medication in its originally received container, that Licensee’s staff did not display skill/knowledge regarding medication assistance, and that Licensee’s staff did not meet reporting requirements regarding incident. [See LIC 811 Confidential Names List for a description of select person identifiers used in this report.] CCLD’s investigation involved multiple unannounced facility tours/welfare check and review of relevant care, medication, and San Diego Regional Center (SDRC) audit records. The Department also interviewed all clients in care and pertinent staff and outside sources. [CONTINUED ON LIC 9099-C, 1 of 3]
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2025
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 6
Control Number 08-AS-20250425161712
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: TIZON'S PRIME CARE INC
FACILITY NUMBER: 374603824
VISIT DATE: 06/09/2025
NARRATIVE
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[CONTINUED FROM LIC 9099]

Records and interviews showed: Near the end of February 2025, Licensee self-recognized that C1’s pharmacy had not yet delivered to the facility refills of C1’s once-daily Aspirin and Bupropion medications to cover March 2025. Licensee contacted both C1’s pharmacy and the office of C1’s prescribing psychiatrist trying to resolve these issues. Licensee was told these refills could not be dispensed because C1’s psychiatrist needed to first authorize their replenishment. Also, C1’s pharmacy on 02/28/2025 contacted the prescribing psychiatrist's office directly to advise them of the situation and to seek clarification regarding medication orders. Despite constructive knowledge that C1 was about to run out of Aspirin and Bupropion pills, C1’s psychiatrist insisted they needed to first meet C1 for an appointment, and the next available appointment would not be until 03/26/2025. C1 subsequently attended an in-person appointment with their psychiatrist on 03/26/2025, after which point the doctor released the refills. Supplies of C1’s Aspirin and Bupropion pills were delivered from the pharmacy to the facility on 03/27/2025, at which point Licensee’s staff resumed giving these two medications to C1. CCLD concluded that the psychiatrist’ actions, from a practical standpoint, constituted a hold/pauser order. Licensee was therefore not culpable for C1 not receiving their Aspirin and Bupropion pills from 03/01/2025 through 03/26/2025.

Although C1’s missed Aspirin and Bupropion doses during March 2025 were not, strictly speaking, “medication errors,” the sudden/unplanned interruptions of these medications was required to be reported to C1’s authorized representative (who was their SDRC coordinator). Interviews of facility managers and SDRC personnel confirmed they were not timely reported, either verbally or via written report. SDRC personnel self-discovered the interruptions during their 03/27/2025 facility inspection/audit

Interviews of Licensee and San Diego Regional Center (SDRC) personnel, corroborated by SDRC records, further showed: Licensee staff on 04/21/2025 did not give C1 their once-daily routine Ferosul (iron) tablet in the morning, as prescribed. SDRC personnel discovered this during a site visit that day, bringing it to the attention of Licensee. Licensee thus gave C1 their Ferosul tablet on 04/21/2025 in the afternoon, which was late (i.e., not at the prescribed time). This constituted a medication error, which Licensee reported to C1’s prescribing doctor, and which Licensee subsequently timely reported in writing to SDRC and CCLD via Special Incident Report (SIR), as required.

[CONTINUED ON LIC 9099-C, 2 of 3]
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 08-AS-20250425161712
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: TIZON'S PRIME CARE INC
FACILITY NUMBER: 374603824
VISIT DATE: 06/09/2025
NARRATIVE
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[CONTINUED FROM LIC 9099-C, 1 of 3]

During CCLD’s investigation, LPA audited Medication Administration Records (MARs) for C1 and their five housemates [Client #2 (C2) through Client #6 (C6)] for the period from 03/02/2025 through 04/29/2025. CCLD found additional medication errors: Aside from the above-mentioned incident with C1’s Ferosul tablet, Licensee’s staff had given C1 their as-needed (PRN) cough medicine twice per day from 03/02/2025 through 03/08/2025, and again from 03/10/2025 through 03/25/2025. The prescription label for C1’s PRN cough medicine said it was to be given for ten (10) days at most. From 03/02/2025 through 03/09/2025, Licensee’s staff applied a topical gel to C2’s right knee three (3) times per day, instead of the prescribed two (2) times per day. From 03/21/2025 through 03/31/2025, Licensee’s staff gave C2 their routine Calcium Antiacid tablet only in the morning, when the prescription said it was supposed to be given three (3) times per day (e.g., one at each meal). Licensee’s staff had given C3 their PRN cough medicine twice per day from 03/02/2025 through 03/08/2025, and again from 03/11/2025 through 03/26/2025. The prescription label for C1’s PRN cough medicine said it was to be given for ten (10) days at most. LPA discovered the above during his own audit; they were not communicated from Licensee to CCLD prior to the complaint.

Interviews of Licensee and San Diego Regional Center (SDRC) personnel, corroborated by SDRC records, showed: C1’s morning Vitamin C tablet was given to them on 03/26/2025, but staff did not timely initial for it in the MAR. C1’s PM medications on 03/26/2025 and their AM medications on 03/27/2025 were given to C1, but staff did not timely initial for them in the MAR. C2’s PM medications on 03/26/2025 and their AM medications on 03/27/2025 were given to C2, but staff did not timely initial for them in the MAR. The staff responsible for this missing documentation was former caregiver Staff #1 (S1), who no longer works at the facility. Per interviews of facility managers, S1 gave the medications to C1 and C2, respectively, but just didn’t sign for them immediately because S1 was “too busy” to do so, and this was inconsistent with Licensee’s training/expectations for staff.

During his own audit of MARs, LPA observed: Regarding C2’s one-daily routine Lidocaine patch, there were six (6) days in March 2025 when staff did not initial showing that the old patch was removed and replaced with a new patch. There were no corresponding notes to explain why. Regarding C3’s routine Calcium/Vitamin D3 supplement, there were two (2) days in March 2025 when staff did not initial showing that it had been given to C3. There were no corresponding notes to explain why. [CONTINUED ON LIC 9099-C, 3 of 3]
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 08-AS-20250425161712
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: TIZON'S PRIME CARE INC
FACILITY NUMBER: 374603824
VISIT DATE: 06/09/2025
NARRATIVE
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[CONTINUED FROM LIC 9099-C, 2 of 3] On the morning of 04/28/2025, Licensee’s staff did not initial that C4 had received their routine Pantoprazole tablet, as prescribed. There were no corresponding notes to explain why. Staff also did not initial that C4 had received their routine topical cream, which was prescribed at a frequency of twice per week. There were no corresponding notes to explain why. CCLD was unable to determine if the MAR omissions described in this paragraph represented actual missed doses, or if they were only missed documentation. During the reviewed period, staff initials in the MAR indicated three (3) of the six (6) clients in care had at some point received as-needed medication doses, but staff did not record the times these PRNs were given or the outcome / how the client felt after receiving them.

Interviews of Licensee and San Diego Regional Center (SDRC) personnel, corroborated by SDRC records, showed: C1’s Vitamin C tablet was a centrally-stored medication. On 03/27/2025, a facility caregiver had pre-poured/pre-popped C1’s Vitamin C tablet for the following day (03/28/2025), transferring it to a separate container. Regulation requires all centrally stored medications to be stored in their original pharmacy packaging. In this case, the Vitamin C tablet should have remained in its blister-pack until it was time for C1 to take that pill.

Based on records and interviews, a preponderance of evidence exists to show Licensee did not give client medication as prescribed, Licensee did not store client's medication in its originally received container, Licensee’s staff did not display skill/knowledge regarding medication assistance, and Licensee’s staff did not meet reporting requirements regarding incident. These allegations were Substantiated, and four (4) deficiencies were cited for them per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D pages). Plans of Correction were jointly developed with the Licensee.

Per, their latest respective LIC602 Physician’s Reports showed R1 through R6 all depended on staff for assistance with medications. The Department did not find evidence of a client suffering any adverse health outcome resulting from a medication issue.

An exit interview was conducted with Licensee/Administrator Grace Cosico and Manager Reginald Cosico, to whom a copy of this report, the LIC 9099-D pages, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 08-AS-20250425161712
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: TIZON'S PRIME CARE INC
FACILITY NUMBER: 374603824
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/09/2025
Section Cited
CCR
80075(b)
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80075 Health Related Services: “(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.” This requirement was not met, as evidenced by:
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Training records showed Licensee on 05/09/2025 had all current staff receive remedial medication-assistance training from the facility’s third-party contracted pharmacy. This satisfies the deficiency. Going forward, Licensee was encouraged to have each direct-care staff individually attend the pharmacy’s longer 8-hour medication class (typically offered once per quarter), as quickly as staffing levels will permit.
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Records and interviews showed that Licensee did not give at least 3 of 6 clients (C1, C2, and C3) their medications as prescribed. This posed a potential health risk to persons in care.
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Type B
06/09/2025
Section Cited
CCR
80075(k)(5)
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80075 Health Related Services: “(k) The following requirements shall apply to medications which are centrally stored: (5) Each client's medication shall be stored in its originally received container.” This requirement was not met, as evidenced by:
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Training records showed Licensee on 05/09/2025 had all current staff receive remedial medication-assistance training from the facility’s third-party contracted pharmacy. This satisfies the deficiency. Going forward, Licensee agreed to continue reminding/reinforcing to staff that pre-pouring of medications is not allowed.
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Records and interviews showed Licensee did not store a medication for 1 of 6 clients (C1) in its originally received container from the pharmacy. This posed a potential health 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: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 08-AS-20250425161712
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: TIZON'S PRIME CARE INC
FACILITY NUMBER: 374603824
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/09/2025
Section Cited
CCR
80065(f)(4)
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80065 Personnel Requirements: “(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance. (4) Assistance with prescribed medications which are self-administered.” This requirement was not met, as evidenced by:
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Training records showed Licensee on 05/09/2025 had all current staff receive remedial medication-assistance training from the facility’s third-party contracted pharmacy. This satisfies the deficiency. Going forward, Licensee was encouraged to have each direct-care staff individually attend the pharmacy’s longer 8-hour medication class (typically offered once per quarter), as quickly as staffing levels will permit.
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Records and interviews showed Licensee did not ensure all personnel could evidence safe and effective job performance in assisting with prescribed medications which are self-administered. This posed a potential health risk to 6 of 6 clients (C1 through C6) in care.
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Type B
07/09/2025
Section Cited
CCR
80061(b)(1)(E)
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80061 Reporting Requirements: “(b) Upon the occurrence…of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report…shall be submitted to the licensing agency within seven days… (1) Events reported shall include the following: (E) Any unusual incident… which threatens the physical…health or safety of any client.” This requirement was not met, as evidenced by:
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As of the date of deficiency issuance, Licensee has submitted a written report for the indicated incident (involving C1) to CCLD and San Diego Regional Center (SDRC). Per Licensee interview, facility staff and managers are already enrolled in an upcoming Special Incident Report (SIR) training to be led by SDRC on 06/11/2025. Upon completion of the class, but no later than the POC due date, Licensee agreed to E-mail proof of training completion to LPA.
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Records and interviews showed 1 of 6 clients (C1) had an incident which potentially threatened their physical health, and of which Lincesee had constructive knowledge, yet Licensee did not report it to the licensing agency within the next working day and did not submit a written report to the licensing agency within seven days. This posed a potential health 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: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6