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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604267
Report Date: 08/25/2026
Date Signed: 08/25/2026 03:40:42 PM

Document Has Been Signed on 08/25/2026 03:40 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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, LLCFACILITY NUMBER:
374604267
ADMINISTRATOR/
DIRECTOR:		SUURONEN-GOODWIN, TIAFACILITY TYPE:
740
ADDRESS:4171 CAMINO DEL RIO SOUTHTELEPHONE:
(619) 283-2226
CITY:SAN DIEGOSTATE: CAZIP CODE:
92108
CAPACITY: 70CENSUS: 61DATE:
08/25/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:31 PM
MET WITH:Executive Director Candi LairdTIME VISIT/
INSPECTION COMPLETED:
03:35 PM
NARRATIVE
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Licensing Program Analyst(LPA) Janet Ngallo conducted an unannounced Case Management - Deficiencies Visit. LPA was greeted by, introduced themselves to, and discussed the purpose of the visit with Executive Director Candi Laird.

LPA was at the facility regarding unrelated complaints and during the facility visit, LPA received information from a staff member(S1) indicating that a false claim was made regarding another complaint case [08-AS-20260803145557]. S1 reported that administration had instructed them to provide inaccurate information to licensing. S1 stated they had not been scheduled to work during the time in question and reported receiving text message and verbal instructions from administration directing them to state that they had left the facility and later returned, when in actuality, S1 was not scheduled for the afternoon shift, resulting in delayed medication administration.

A review of the staffing schedule for the week of August 2, 2026 through August 8, 2026 revealed that on August 2, 2026, the PM shift (2:00 PM-10:30 PM) medication technician assignment listed one medication technician assigned and one unfilled slot, S1 was not listed for the shift.

Review of text message correspondence between S1 and administration showed messages in which administration directed S1 to report to licensing that they had left the facility for two hours and returned.

One deficiency is being cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D page). A plan of correction was jointly developed with the licensee. An exit interview was conducted with Executive Director Candi Laird and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided. Their signature confirms receipts of these documents.

Lizzette Tellez
Janet Ngallo
DATE: 08/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 08/25/2026 03:40 PM - It Cannot Be Edited


Created By: Janet Ngallo On 08/25/2026 at 01:10 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: CLOISTERS OF THE VALLEY, LLC
FACILITY NUMBER: 374604267

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/25/2026
Section Cited
CCR
87207

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87207 No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement was not met as evidenced by:

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Licensee self-certifies their understanding of this requirement, and has signed the attestation for self-correction under penalty of perjury. Licensee stated they will comply with this regulation throughout the duration of facility operation. The previous Executive Director that was operating the facility during the false claim is no longer employed by the facility.

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Based on interviews and records review, the licensee provided false and misleading statements to the licensing agency regarding the staffing schedule for who was on shift to provide medications for residents. This posed a potential health and safety risk to residents 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.
Lizzette Tellez
NAME OF LICENSING PROGRAM MANAGER:
Janet Ngallo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2026


LIC809 (FAS) - (06/04)
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