374604115-10-7-2025-18-AS-RORN-DMPQ5S-20251022115225

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604115
Report Date: 10/07/2025
Date Signed: 10/07/2025 03:51:47 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
10/04/2022 and conducted by Evaluator Deborah Lee

COMPLAINT CONTROL NUMBER: 18-AS-20221004165817

FACILITY NAME:	COUNTRY ROSE ESTATE MEMORY CARE		FACILITY NUMBER:	374604115
ADMINISTRATOR:	PARAISO, CATHERINE T		FACILITY TYPE:	740
ADDRESS:	1255 ADVENTURE LN		TELEPHONE:	(760) 738-9391
CITY:	SAN MARCOS	STATE: CA	ZIP CODE:	92069
CAPACITY:	15	CENSUS: 14	DATE:	10/07/2025
		UNANNOUNCED	TIME BEGAN:	11:43 AM
MET WITH:	Val Paraiso		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Resident is being physically abused

INVESTIGATION FINDINGS:

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On October 7, 2025, the Department of Social Services staff conducted an unannounced visit to this facility to continue investigation of the above allegation and to deliver findings. The Department was met by Damien Flores, care provider, and subsequently with Administrator Val Paraiso via telephone and the purpose of the visit was explained.
Investigation consisted of the following:
On 10/13/22, the Department conducted an unannounced initial visit to the facility to investigate the complaint allegation mentioned above. During the visit, it was determined that the complaint required further investigation.
On 10/7/2025 the Department toured the facility, interviewed Administrator (A1), 4 staff and 3 residents 1 Witnesses (W1). The Department reviewed the following documents (obtained from prior visit): San Diego County suspected Elder/Dependent Adult Abuse report (dated 10/2/22), R1's ID and Emergency information form (dated: 11/18/16), R1's Physicians report (dated 2/22/19, 4/6/18), R1's Pre-placement appraisal (dated 11/24/14), Letter of Conservatorship (dated 5/3/24), R1’s Needs and Services Plan (date 8/9/19),R1's 30-day eviction Notice (dated 8/14/22). On 10/7/25, the Department obtained and reviewed copy of staff roster, resident roster.
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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025

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 18-AS-20221004165817

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: COUNTRY ROSE ESTATE MEMORY CARE	FACILITY NUMBER: 374604115
	VISIT DATE: 10/07/2025

NARRATIVE

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The investigation revealed the following:

Allegation: Resident is being physically abused

The detail of complaint alleges that R1 is being physically abused at the facility.

On 10/7/25, the Department interviewed Administrator (A1), who denied the allegation stating that the above allegation is false and that R1 was never abused at the facility. He went on to state that R1’s father, conservator, psych nurse and Social Work can all attest to that.

On 10/7/25, the Department interviewed 4 staff regarding the allegation, and of those interviewed, 3 out of 4 was not on staff during the time the allegation was made. However, 4 out of 4 stated that they have never abused a resident and have never witnessed any other staff abusing a resident in care. Additionally, 4 out of 4 state that they have received client’s right’s training.

On 10/7/25, the Department interviewed 3 residents about their treatment at the facility and if they have ever been hit by a staff. Of those interviewed 3 out of 3 stated that they are treated well at the facility and have never been abused.

The Department obtained, reviewed and evaluated the following documents: R1’s pre-placement appraisal (11/24/14), Needs and Services Plan ( 8/1/19), letter of conservatorship (5/3/24) and 30-day notice from facility outlining reason for eviction (dated 8/14/22)

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SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20221004165817

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: COUNTRY ROSE ESTATE MEMORY CARE	FACILITY NUMBER: 374604115
	VISIT DATE: 10/07/2025

NARRATIVE

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On 10/7/25 via telephone the Department interviewed Witness #1 (W1), who denied the allegation stating that it did not occur. W1 went on to state that the Department can “close the investigation, because the facility did not abuse R1.”

Based on the information gathered, there is insufficient evidence to support the allegation mentioned above; Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

There were no deficiencies cited during today's visit.

Exit interview conducted and copy of report provided.

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SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025

LIC9099 (FAS) - (06/04)

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