374604100-5-23-2025-08-AS-APEZ-DH5KVQ-20250529081439

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604100
Report Date: 05/23/2025
Date Signed: 05/23/2025 12:10:34 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/19/2020 and conducted by Evaluator Javina George

PUBLIC

COMPLAINT CONTROL NUMBER: 08-AS-20201019105341

FACILITY NAME:	CASA DEL SOL RTF II		FACILITY NUMBER:	374604100
ADMINISTRATOR:	VASQUEZ, MANUEL		FACILITY TYPE:	735
ADDRESS:	1141 JULIETTE PL		TELEPHONE:	(619) 405-7750
CITY:	FALLBROOK	STATE: CA	ZIP CODE:	92028
CAPACITY:	4	CENSUS: 0	DATE:	05/23/2025
		UNANNOUNCED	TIME BEGAN:	11:40 AM
MET WITH:	Manuel Vasquez, Licensee/Administrator		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Resident sustained fracture due to neglect/lack of supervision.
Resident sustained bruising due to neglect/lack of supervision
Staff did not seek medical attention for resident in a timely manner.

INVESTIGATION FINDINGS:

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On 05/23/25 Licensing Program Analyst (LPA) Javina George arrived at facility unannounced to deliver findings for the complaint investigation related to the above listed allegation. LPA Javina George met with Manuel Vasquez, Licensee/Administrator and explained the purpose of today’s visit.

Regarding the allegations of client sustaining a fracture due to staff neglect/lack of supervision, as well as bruising due to staff neglect/lack of supervision, interviews and record reviews were conducted. A review of an Unusual Injury/Incident Report dated 09/22/2020 revealed staff reported Client 1 (C1) tripped and fell on 09/19/2020, hitting their face on the floor. This caused C1’s left eye to swell and get purple. A review of an Unusual Injury/Incident Report dated 10/01/2020 revealed staff reported C1 had a strange swelling on their left buttock noticed on 09/13/2020 but the next day the swelling was gone. It further read that C1 left the facility on 09/26/2020 with non-staff individuals and during this time, C1 complained of discomfort to their back. C1 was taken to the hospital which revealed a fracture. The report further revealed staff would monitor C1 closely and collect data on C1 dropping themselves to the floor on their own.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20201019105341

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CASA DEL SOL RTF II	FACILITY NUMBER: 374604100
	VISIT DATE: 05/23/2025

NARRATIVE

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C1’s physician report dated 02/14/2020 revealed C1 is ambulatory and under the category “able to communicate” a note is written reading “non-verbal”. Progress Report dated 08/27/2020 identifies a goal of working on a target behavior of dropping to the floor. The report indicated C1 had 55 episodes of this behavior and noted it was a significant increase from the previous quarter.

Medical records were reviewed and corroborated C1 arrived on 09/26/2020 and was diagnosed with acute lumbar fractures and acute lumbar hematoma. Medical records read a hematoma is a collection of blood trapped outside of a blood vessel. It further reads “It is what we think of as a bruise or a contusion.” Staff interviewed denied abuse or being physically aggressive with clients.

During the course of the investigation a video surfaced of facility staff physically abusing clients. One of the clients was identified as C1. The date of the video could not be identified and therefore could not be tied to this injury or bruising. The Department has taken separate action regarding the video in question.

Regarding the allegation of staff not seeking timely medical attention, it was alleged that staff had reported C1 had been crying on 09/26/2020 before C1 left on outing with non-facility staff. When asked what had been done or could be happening, staff answered they did not know what to do or how to calm C1 down. Interviews with non-staff revealed the names of 2 staff who made this claim. Interviews with both staff did not corroborate the statement.

Based on the interviews conducted and the records reviewed, the investigation did not provide sufficient evidence to substantiate the allegations and as such, the allegations are unsubstantiated.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

An exit interview was conducted and a copy of this report, a confidential names list (LIC 811) and appeal rights were provided Licensee/Administrator Manuel Vasquez.

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2025

LIC9099 (FAS) - (06/04)

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