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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603824
Report Date: 10/16/2025
Date Signed: 10/16/2025 11:28:07 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
10/09/2025 and conducted by Evaluator Tiffany Holmes
COMPLAINT CONTROL NUMBER: 08-AS-20251009151507
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:
10/16/2025
UNANNOUNCEDTIME BEGAN:
09:59 AM
MET WITH:Caregiver Nelson Baul,TIME COMPLETED:
11:28 AM
ALLEGATION(S):
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Facility is unsanitary
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced visit to investigate the allegation listed above. LPA was greeted by Caregiver Nelson Baul, who was informed of the purpose of the visit.

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 October 9, 2025, Community Care Licensing (CCL) received a complaint alleging that the facility is unsanitary. Interviews revealed that on October 6th, 2025, approximately around 11 :30 am Client 1 (C1) was eating their lunch when C1 informed the staff that there were critters. Interviews revealed they observed approximately cockroaches eating food that had fallen on C1's wheelchair. Interviews revealed that C1 was transferred to an armchair and their wheelchair was taken outside. Interviews revealed that once the wheelchair was outside it was observed that there were about 15-20 roaches on it and in it. Interviews revealed there were cockroaches in the cushion of C1's wheelchair and upon further observation, they saw dead cockroaches as well. Interviews with staff revealed the day program called them and advised them of them incident. The investigation determined that the facility is aware of and has attempted to treat the roach problem. Staff interviews revealed they called a Pest conrtrol to spray for the bugs and that they did not see any in plain sight, although they found some in the baseboards.

(Continue at LIC9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025
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-20251009151507
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: 10/16/2025
NARRATIVE
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 Staff interviews revealed they were spraying several rooms in the house due to this incident. Staff interviews revealed that Atomic Pest control came out and sprayed the kitchen, bedframes, monitor station and the interior baseboards for German roaches on October 13, 2025.

Staff interviews also revealed they switched C1s wheelchair out and gave them a new one. Outside sources also reported that the client had a new wheelchair as well.

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 the LIC 9099-D.

An exit interview was conducted with Staff Nelson Baul and a copy of this report and the Licensee Appeal Rights (LIC 9058 03/22) were provided at the conclusion of the visit.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 08-AS-20251009151507
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: 10/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/24/2025
Section Cited
CCR
80087(a)(1)
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80087 Buildings and Grounds. (a)(1) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. The licensee shall take measures to keep the facility free of flies and other insects.
This req't was not met as evidenced by:
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Licensee Cosico secured pest control treatment provided by an outside professional pest control service provider. Administrator agreed to provide proof of service contract and invoice/receipt to CCL by 10/24/2025.
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Based on observations and interview, the licensee did not keep the facility sanitary or free from roaches. This posed a potential health risk to 6 of 6 (C1) clients 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: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3