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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604282
Report Date: 03/16/2026
Date Signed: 03/17/2026 01:37:43 PM

Substantiated


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
10/21/2025 and conducted by Evaluator Tiffany Holmes
COMPLAINT CONTROL NUMBER: 08-AS-20251021102652
FACILITY NAME:ABIGAIL'S HOMES IIIFACILITY NUMBER:
374604282
ADMINISTRATOR:GONZALEZ, BRENDA ABIGAILFACILITY TYPE:
735
ADDRESS:2505 ARCADIA AVETELEPHONE:
(619) 439-7791
CITY:LEMON GROVESTATE: CAZIP CODE:
91945
CAPACITY:4CENSUS: 2DATE:
03/16/2026
UNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Administrator Raquel GarciaTIME COMPLETED:
12:08 PM
ALLEGATION(S):
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Resident AWOL
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA)Tiffany Holmes contacted the facility to deliver findings for a complaint investigation via tele-virtual. LPA identified herself to, and explained the purpose of the visit and the basic elements of the complaint with Assistant Administrator Raquel Garcia.

LPA Domingo previously conducted the initial visit on October 28, 2025 and conducted interviews with residents, staff, outside sources, and obtained and reviewed pertinent records. On March 9, 2025 the complaint was reassigned to LPA Holmes. It was alleged that the client went AWOL. Interviews revealed that Client 1 (C1) went AWOL to go to Walgreens. Interviews revealed that C1 was upset because the staff wanted to them to return the other clients rapid card. Interviews revealed that staff searched for C1 at the businesses near the facility. Interviews revealed that the am/pm staff stated that C1 used the atm and left. Interviews revealed that when staff could not locate C1 they called 911. Interviews revealed that the police officers located C1 in front of Walgreens with items they purchased. Interviews revealed that C1 was then taken to the hospital ER for an evaluation and C1 returned home at approximately 11:00 pm. Interviews revealed that their supervision protocols are in place to prevent clients from leaving unsupervised but the clients still leave if they want even after staff redirection. According to C1’s Physician’s Report dated 07/25/2025 shows that C1 is not able to leave the facility unassisted. The client is diagnosed with Schizophrenia.
Outside source interviews revealed that C1left that day, and returned and right after that he went back to the hospital.

Based on interviews, observations and records reviewed, the allegation is substantiated. The allegation is valid and a preponderance of the evidence proved the alleged violation occurred.

An exit interview was conducted with Assistant Administrator Raquel Garcia, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to at the conclusion of the visit.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2026
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 4
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
10/21/2025 and conducted by Evaluator Tiffany Holmes
COMPLAINT CONTROL NUMBER: 08-AS-20251021102652

FACILITY NAME:ABIGAIL'S HOMES IIIFACILITY NUMBER:
374604282
ADMINISTRATOR:GONZALEZ, BRENDA ABIGAILFACILITY TYPE:
735
ADDRESS:2505 ARCADIA AVETELEPHONE:
(619) 439-7791
CITY:LEMON GROVESTATE: CAZIP CODE:
91945
CAPACITY:4CENSUS: DATE:
03/16/2026
UNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Administrator Raquel GarciaTIME COMPLETED:
12:08 PM
ALLEGATION(S):
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9
The resident was served uncooked food and became ill.
The staff did not treat the resident with dignity.
The staff did not treat the resident with respect.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA)Tiffany Holmes contacted the facility to deliver findings for a complaint investigation via tele-virtual. LPA identified herself to, and explained the purpose of the visit and the basic elements of the complaint with Assistant Administrator Raquel Garcia.

LPA Domingo previously conducted the initial visit on October 28, 2025 and conducted interviews with residents, staff, outside sources, and obtained and reviewed pertinent records. On March 9, 2025 the complaint was reassigned to LPA Holmes. It was alleged that the resident was served uncooked food and became ill. Interviews revealed that Client 1 (C1) didn't remember but stated that maybe they ate burgers but stated they weren't sick. Interviews revealed that C1 helps cook their food and that they know what cook food looks like and tastes like. C1 stated that they have a lot of food and that they would not eat uncooked food. Interviews revealed on 10/17/2025 that they all went to McDonalds on that day. Interviews revealed that the staff normally don't temper check the food before serving the food. Interviews also revealed when they cook at the facility the client's help prepare the food so they choose what to eat and they know what is in the meal because they help prepare the food. Interviews with staff revealed there were no complaints about the food and that no one complained about any illness that day. Interviews revealed the staff have all had food safety training upon hire. Interviews with staff revealed that C1 and C2 make their own lunch with minimal staff assistance. Outside source interviews revealed that C1 has not made any complaints about the food being raw or uncooked.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 08-AS-20251021102652
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: ABIGAIL'S HOMES III
FACILITY NUMBER: 374604282
VISIT DATE: 03/16/2026
NARRATIVE
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It was alleged that the staff did not treat the resident with dignity. Interviews revealed the clients feel staff treat them with respect but mentioned they don't like to be bothered sometimes. Interviews revealed that the staff hasn't spoken to them in a way that made them feel uncomfortable or disrespected. Interviews revealed that they like when the staff give them time to talk and that makes them feel heard. Interviews revealed the staff make them feel safe. Interviews with an outside source revealed that C1 has not made any complaints against the staff not treating them with dignity.

It was alleged that the staff did not treat the resident with respect. Interviews revealed the staff speak to them with respect. Interviews revealed there is one client that is very moody and can be aggressive and may complain one day and retract what they stated because they were angry. Interviews revealed that the staff give the clients space to calm down when they are upset and speak to them calmly and respectfully. Interviews revealed that they have not witnessed or heard the staff disrespectfully speaking to the other clients.
Outside source interviews revealed that C1 has not made any complaints against the staff or the facility

Based on interviews, observations and records reviewed, The allegations may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred.

An exit interview was conducted with Assistant Administrator Raquel Garcia, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to at the conclusion of the visit.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 08-AS-20251021102652
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: ABIGAIL'S HOMES III
FACILITY NUMBER: 374604282
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/16/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/30/2026
Section Cited
CCR
80065(a)
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80065 Personnel Requirements
(a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs. This requirement is not met as evidenced by:
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Licensee agreed to submit updated AWOL plans for both clients and to train the staff on AWOL procedures and redirection. A sign in sheet along with training materials will be submitted to CCL by POC date of 03/30/2026
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Based on interviews and record review the licensee did not provide supervision for 1 out of 2 clients (C1). This posed an immediate health and safety risk to clients 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.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 4