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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603824
Report Date: 07/17/2025
Date Signed: 07/17/2025 04:11:27 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
04/29/2025 and conducted by Evaluator Marisela Garcia-Centeno
COMPLAINT CONTROL NUMBER: 08-AS-20250429162220
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:
07/17/2025
UNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Caregiver, Nelson BaulTIME COMPLETED:
01:55 PM
ALLEGATION(S):
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Client was not treated with dignity and respect
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced visit to deliver investigative findings related to the allegation listed above. LPA was greeted by Caregiver Nelson Baul, who was informed of the purpose of the visit. LPA then met with Licensee/Administrator Grace Cosico and Manager Reginald Cosico, via telephone and delivered the findings.

The Department investigated the complaint allegation through a facility tour, multiple interviews with staff, clients, and external sources, and a review of client and facility records.

On April 29, 2025, Community Care Licensing (CCL) received a complaint alleging that Client 1 (C1) was not treated with dignity and respect. Specifically, it was alleged that on April 25, 2025, a staff member (S1) rushed C1 while getting them ready and pulled their arm too hard during dressing.

(Continue at LIC9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
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-20250429162220
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: 07/17/2025
NARRATIVE
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(Continue from LIC9099)

A review of C1’s records revealed that C1 had been diagnosed with mild intellectual disability and cerebral palsy. C1 also had a special health condition involving seizures, which resulted in weakness and slowed movement. Records indicated that C1 experiences petit mal seizures and pseudo-seizures that cause body tremors.

During an interview, C1 stated that S1 pulled their arm hard and that the arm remained sore. On May 1, 2025, during a facility visit, C1 reiterated that S1 pulled their arm and again stated the arm was still sore.
S1, during an interview, admitted to raising C1’s arm while assisting with dressing. S1 denied intent to cause harm and said they were simply helping. Staff interviews revealed that S1 was a new employee, still in the process of completing required training and shadowing more experienced staff. The Administrator confirmed that on the day of the incident, S1 was assisting C1 without supervision.

There were no witnesses to the incident. During interviews, C1 reported that they generally feel respected by staff and enjoy living at the facility, stating this was the only instance where they felt rushed to get ready for their day program.
Interviews with other staff and clients indicated this was an isolated incident and not consistent with standard protocol. Staff emphasized the importance of adhering to C1’s care plan, which stated that C1 must be treated gently and given sufficient time during dressing and hygiene routines to prevent injury.

Conclusion:
Based on the investigation, the Department determined that sufficient evidence exists to substantiate the allegation. A substantiated finding indicates that the allegation is valid because the preponderance of evidence standard has been met.

A deficiency was cited in accordance with Title 22, Division 6, Chapter 8 of the California Code of Regulations, as documented on LIC 9099-D. A Plan of Correction (POC) was developed in collaboration with Administrator Grace Cosico.

An exit interview was conducted with Administrator Cosico and Staff Nelson Baul. A copy of this report and the Licensee Appeal Rights (LIC 9058 03/22) were provided at the conclusion of the visit.
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20250429162220
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: 07/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/15/2025
Section Cited
CCR
80065(a)
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80065(a) Personnel Requirements
Facility personnel shall be competent to provide the services necessary to meet individual client needs.

This requirement was not met, as evidenced by:
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The licensee agreed to provide additional training to all staff to ensure proper and safe assistance with activities of daily living, tailored to meet each client’s individual needs. The licensee further agreed to submit documentation verifying completion of the required training by all staff.
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Based on interviews and record review, the licensee did not ensure that all personnel were capable of performing their duties safely and effectively when assisting clients with activities of daily living. This posed a potential health risk to 1 of 6 clients (C1) 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: Sabel Martinez
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
LIC9099 (FAS) - (06/04)
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