374604267-5-6-2026-08-AS-APAO-DUC374-20260522175921

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604267
Report Date: 05/06/2026
Date Signed: 05/06/2026 12:05:15 PM

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
04/09/2026 and conducted by Evaluator Janet Ngallo

COMPLAINT CONTROL NUMBER: 08-AS-20260409110000

FACILITY NAME:	CLOISTERS OF THE VALLEY, LLC		FACILITY NUMBER:	374604267
ADMINISTRATOR:	DISHA FRANCES-HALL		FACILITY TYPE:	740
ADDRESS:	4171 CAMINO DEL RIO SOUTH		TELEPHONE:	(619) 283-2226
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92108
CAPACITY:	70	CENSUS: 67	DATE:	05/06/2026
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Executive Director Tia Suuronen-Goodwin		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Staff did not ensure residents records were kept safely secured.
Staff mismanaged residents records.
Licensee does not ensure staff are adequately trained.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Janet Ngallo conducted an unannounced subsequent visit to deliver findings regarding the above mentioned allegations. LPA identified themselves and met with Executive Director Tia Suuronen-Goodwin to discuss the purpose of the visit and elements of the complaint.

On 04/09/2026, it was alleged that staff did not ensure residents records were kept safely secured, staff mismanaged residents records, and that the licensee does not ensure staff are adequately trained. The department's investigation consisted of interviews, observations, and records review.

Regarding the allegation that staff did not ensure residents records were kept safely secured, interviews reported that resident records are kept in locked cabinets at the front desk or in designated administrative offices. Staff stated they were trained on securing documents, including storing files when stepping away and minimizing electronic screens. Staff reported they have not witnessed any unsecured records left out in common areas. (Cont. on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Janet Ngallo
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2026

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-20260409110000

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: CLOISTERS OF THE VALLEY, LLC	FACILITY NUMBER: 374604267
	VISIT DATE: 05/06/2026

NARRATIVE

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(Cont. on LIC 9099)

Records review of facility employee training materials revealed instruction on confidentiality and safeguarding resident information. Facility manuals contained procedures for faxing, scanning, and securing physical and electronic records. Records review of staff job descriptions emphasized confidentiality requirements in all matters including but not limited to resident and employee information.

LPA observed the front desk area clean and organized, with no records left out. Staff demonstrated accessing locked cabinets with a key, and resident files were observed stored and organized inside the secured cabinets.

Regarding the allegation that staff mismanaged residents’ records, interviews reported consistent procedures for receiving, alphabetizing, scanning, uploading, and filing resident documents. Staff denied sending records to incorrect providers or mishandling resident information. Staff indicated that if any errors occurred, they were incoming documents from external senders, not errors caused by facility staff.

Regarding the allegation that the licensee does not ensure staff are adequately trained, interviews reported receiving training through a third party training portal, hands-on instruction, and shadowing by former experienced staff. Administrative staff stated that new hires receive job-specific training and ongoing guidance. Staff reported having access to manuals and training materials for front desk procedures and record handling.

LPA review of training records showed completion of HIPAA, confidentiality, and job-specific modules and front desk manuals included step-by-step instructions for administrative tasks.

The Department has investigated the above-mentioned allegations and 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 therefore deemed unsubstantiated.

An exit interview was conducted with Executive Director Tia Suuronen-Goodwin, to whom a copy of this report and the Licensee’s Rights (LIC9058 01/16) were provided.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Janet Ngallo
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2026

LIC9099 (FAS) - (06/04)

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