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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604087
Report Date: 05/05/2026
Date Signed: 05/05/2026 10:35:21 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
01/23/2023 and conducted by Evaluator Tiffany Holmes
COMPLAINT CONTROL NUMBER: 08-AS-20230123160110
FACILITY NAME:MOUNTAIN VIEW HOME-DEL VISTA WAYFACILITY NUMBER:
374604087
ADMINISTRATOR:RUSSELL, KATRINAFACILITY TYPE:
735
ADDRESS:16350 DEL VISTA WAYTELEPHONE:
(619) 419-9938
CITY:EL CAJONSTATE: CAZIP CODE:
92021
CAPACITY:4CENSUS: 3DATE:
05/05/2026
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Eryn Nurse, House ManagerTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Medications were not stored as required
Dangerous items were accessible
Facility bathroom was in disrepair
Licensee did not follow reporting requirements
Licensee did not meet food supply requirements
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced visit to deliver findings regarding the above-mentioned allegations. LPA identified herself and met with Eryn Nurse, House Manager, to discuss the purpose of the visit and elements of the complaint.

The Department's investigation included interviews and review of pertinent records. On 01/23/ 2023. It was alleged that medications were not stored as required.
Interviews revealed medications such as a client's sinus rinse and hydrogen peroxide were not locked and accessible to clients in care. Interviews also revealed that the Medical Administration Record (MAR's) were not initialed or sighned by each staff documenting that the medicine was given to the client.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2026
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-20230123160110
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: MOUNTAIN VIEW HOME-DEL VISTA WAY
FACILITY NUMBER: 374604087
VISIT DATE: 05/05/2026
NARRATIVE
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It was alleged that dangerous items were accessible. Interviews revealed that
there were Clorox wipes that were not locked. Interviews revealed also that the laundry room with all the supply of chemicals and some cans of paint were not locked either. Interviews and outside source observation revealed that the knifes were not properly stored and accessible to clients in care.

It was alleged that the facility bathroom was in disrepair. Interviews revealed there were holes in the walls and the back of the toilet was covered with wood. Interviews also revealed that there were no paper towels in the bathroom due to a client using the paper towels to clog the toilet.

It was alleged that licensee did not follow reporting requirements. Interviews revealed
that the clients Personal and Incidental (P&I) money was stolen in the month of December 2022 and that the facility did not report the incident to the police, San Diego Regional Center (SDRC) or Community Care Licensing (CCL). Interviews revealed that the administrator replaced the money but a SIR needed to be completed to report the incident.

It was alleged that licensee did not meet food supply requirements. Interviews revealed
that the facility refrigerator did not have an adequate supply of milk for the clients to drink.
The allegations of medications were not stored as required, dangerous items were accessible, facility bathroom was in disrepair, licensee did not follow reporting requirements and licensee did not meet food supply requirements is substantiated.

An exit interview was conducted with Eryn Nurse, House Manager A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided and their signature on this report confirms receipt of the Licensee Rights.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 08-AS-20230123160110
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: MOUNTAIN VIEW HOME-DEL VISTA WAY
FACILITY NUMBER: 374604087
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/14/2026
Section Cited
CCR
80087(g)
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Buildings and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.This requirement is not met as evidenced by:
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Licensee will provide training to staff on keeping certain items locked and secured inaccessible to clients in care.Training sign in sheet and materails requried. POC due to CCL by 05/14/2026
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During the visit, the outside source observed medications such as sinus rinse and hydrogen peroxide were not locked, unsecured and accessible to clients to care.

This posed an immediate safety risk to 3 out of 3 clients(C1,C2, C3)
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Type A
05/01/2026
Section Cited
CCR
80087(a)(2)
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80087 Buildings and Grounds (a) 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.
(2) The licensee shall provide for the safe disposal of water and other chemicals used for cleaning purposes.
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Licensee will provide training to staff on keeping the facility clean and safe and what the cleaning procedures are. Training sign in sheet and materails requried. POC due to CCL by 05/14/2026
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During the visit, the outside source observed Dangerous items as in clorox wipes and cans of paint were accessible to 3 out of 3 clients(C1,C2, C3)

This posed an immediate safety risk to 3 out of 3 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: 05/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 08-AS-20230123160110
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: MOUNTAIN VIEW HOME-DEL VISTA WAY
FACILITY NUMBER: 374604087
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/05/2026
Section Cited
CCR
80087(a)
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(a) 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. This requirement is not met as evidenced by:
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Licensee remodeled the downstairs bathroom in question and there is no safety risk to clients. POC Cleared
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During the visit, the outside source observed the acility bathroom was in disrepair.

This posed a potential safety risk to 3 out of 3 clients(C1,C2, C3)
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Type B
05/14/2026
Section Cited
CCR
80061(a)
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80061 Reporting Requirements (a) Each licensee or applicant shall furnish to the licensing agency reports as required by the Department, including, but not limited to, those specified in this section.
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Licensee will provide training to staff onreporting requirements and reportable items. Training sign in sheet and materails requried. POC due to CCL by 05/14/2026
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During the visit, the outside source observed that the licensee did not follow reporting requirements and report an incident when a clients P&I was stolen.

This posed a potential safety risk to 3 out of 3 clients(C1,C2, C3)
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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: 05/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 08-AS-20230123160110
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: MOUNTAIN VIEW HOME-DEL VISTA WAY
FACILITY NUMBER: 374604087
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/01/2026
Section Cited
CCR
80076(a)(1)
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Food Services
(a) In facilities providing meals to clients, the following shall apply:
(1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. Each meal shall meet at least 1/3 of the servings recommended in the USDA Basic Food Group Plan - Daily Food Guide for the age group served. All food shall be selected, stored, prepared and served in a safe and healthful manner.
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Licensee has a refrigerator full of food and milk and there is no safety risk to clients. POC Cleared
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During the visit, the outside source observed that the Licensee did not meet food supply requirements for clients in care.

This posed a potential safety risk to 3 out of 3 clients(C1,C2, C3)
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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: 05/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5