374604208-7-30-2025-08-AS-APAO-DKA2SM-20250805173919

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604208
Report Date: 07/30/2025
Date Signed: 07/30/2025 10:25:48 AM

Unsubstantiated

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
04/08/2025 and conducted by Evaluator Liliana Silveira

PUBLIC

COMPLAINT CONTROL NUMBER: 08-AS-20250408141009

FACILITY NAME:	LIBERTY TRANQUILITY		FACILITY NUMBER:	374604208
ADMINISTRATOR:	CYNTHIA RUIZ		FACILITY TYPE:	737
ADDRESS:	1404 ASH STREET		TELEPHONE:	(760) 625-5106
CITY:	RAMONA	STATE: CA	ZIP CODE:	92065
CAPACITY:	4	CENSUS: 4	DATE:	07/30/2025
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Morgan Davis and Cynthia Ruiz		TIME COMPLETED:	09:30 AM

ALLEGATION(S):

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Staff were not properly trained.
Staff did not ensure there was sufficient food for residents.
Staff did not ensure there was sufficient drinking water for residents.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Liliana Silveira conducted an online meeting through Microsoft Teams with Morgan Davis, Director of Quality Assurance & Training, and Cynthia Ruiz, Program Director, to deliver complaint findings.

The Department’s investigation consisted of observations, interviews and a records review. On April 8, 2025, it was alleged that staff were not properly trained to handle client behaviors. Interviews with staff and an outside source revealed that there was concern regarding a new client, Client #1 (C1), and their high level of behaviors that were injuring staff. An interview with a Department of Developmental Services (DDS) representative revealed that, during a recent inspection, it was determined that the facility had gone “above and beyond” meeting the staff training requirements. The representative also stated that DDS is in continuous contact with the facility to ensure that regulatory and safety requirements are being met. (PAGE 1 OF 3, CONTINUED ON NEXT PAGE, LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Liliana Silveira
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2025

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-20250408141009

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: LIBERTY TRANQUILITY	FACILITY NUMBER: 374604208
	VISIT DATE: 07/30/2025

NARRATIVE

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(PAGE 2 OF 3, CONTINUED FROM PAGE 1, LIC 9099)

A review of facility staff training records revealed that staff were required to take a substantial number of hours of online and in-person training regarding the care and supervision of clients. An interview with the facility Quality Assurance Director (QAD) revealed that since this facility is an Enhanced Behavioral Supports Home (EBSH), client behaviors tend to be very challenging, and clients may hit or bite individuals when they display behavioral issues. The QAD stated that this information is made clear to staff during interviews. The Department also conducted an unannounced facility visit on April 18, 2025, and found that there were a large number of staff present to work with clients. Training materials, as well as a flyer for the Ukeru method, a method used to deescalate behaviors, were also observed. The training method had recently been approved and staff were being trained on how to use the method. There is insufficient evidence to support this allegation.

It was also alleged that there wasn’t sufficient food or drinking water for clients. During the unannounced facility visit on April 18, 2025, it was observed that the facility had a substantial amount of food in two refrigerators and snacks in cabinets in the garage. It was also observed that there were large packets of bottles of drinking water. The interview with the DDS representative revealed that Client #1 (C1) has strong behavioral issues related to food and it was recommended that most of the food be stored in the garage. The DDS representative also stated that C1 tends to break glass and advised the facility to remove most of the food from a glass pantry located in the kitchen. An interview with the QAD also revealed that there are snacks and food available in the kitchen for clients, however, most of the food in the house is currently stored in the garage due to C1’s behaviors. A lead staff also has access to a food card that can be used to purchase food when needed. Water can be provided as bottles or through the water dispenser in the refrigerator. An interview with Client #2 (C2) verified that food was stored in the garage and not as easy to access, but C2 stated that they were still able to get their snacks and water when needed. There is insufficient evidence to support this allegation.

The Department has investigated the allegations that: staff were not properly trained, that staff did not ensure there was sufficient food for residents and that staff did not ensure there was sufficient drinking water for residents. Based upon the information obtained during this investigation, it is determined that the preponderance of evidence was not met to support or corroborate these allegations and they were therefore deemed unsubstantiated. (CONTINUED ON NEXT PAGE, LIC 9099C)

SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Liliana Silveira
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 08-AS-20250408141009

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: LIBERTY TRANQUILITY	FACILITY NUMBER: 374604208
	VISIT DATE: 07/30/2025

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	(PAGE 3 OF 3, CONTINUED FROM LIC 9099C) This report was discussed with Morgan Davis and Cynthia Ruiz. A copy of this report, along with Licensee/Appeal Rights, (LIC 9058 03/22) were provided via email. An email response verifies receipt of the documents.

SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Liliana Silveira
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 3