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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604331
Report Date: 12/08/2025
Date Signed: 12/08/2025 03:17:35 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
09/12/2022 and conducted by Evaluator Manuel Monter
COMPLAINT CONTROL NUMBER: 08-AS-20220912093104
FACILITY NAME:MARANATHA DAY PROGRAMFACILITY NUMBER:
374604331
ADMINISTRATOR:GUIBERT, NICOLEFACILITY TYPE:
775
ADDRESS:1112 BROADWAY, #103TELEPHONE:
(619) 760-3322
CITY:EL CAJONSTATE: CAZIP CODE:
92020
CAPACITY:45CENSUS: DATE:
12/08/2025
ANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator Nicole GuibertTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Lack of staff supervision resulting in serious injury to client.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced investigation visit via phone call to deliver the investigation finding and met with Administrator Nicole Guibert.

On September 12, 2022 the Department received a complaint alleging Lack of staff supervision resulting in serious injury to client. It has been alleged that on September 6, 2022, lack of supervision resulted in a resident pushing another resident, resulting in a fracture.

The Department reviewed Unusual Incident / Injury Report (IR) regarding resident R1, dated September 9, 2022. The IR states, on September 6, 2022, around 9:30am, R1 was walking around a resident pushed him/her. R1 fell straight forward and R1 did catch him/herself from a full fall but did fall completely down. R1 continued with his/her day at the program after. The following day R1 came back to the program and staff S1 noticed R1 seemed to be in pain and 911 was called. Page 1 Out of 3.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2025
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-20220912093104
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: MARANATHA DAY PROGRAM
FACILITY NUMBER: 374604331
VISIT DATE: 12/08/2025
NARRATIVE
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On December 21, 2022 the Department interviewed Licensee / Director Nicole Guibert, referred to as LN. LN confirmed she was present on September 6, 2022 when R1 was pushed by R2. LN stated she was standing directly next to R1, to his/her left by the water fountains, when R2 suddenly pushed R1 from behind. LN stated as R1 began to fall, she was able to partially catch R1 as he/she fell and partially broke his/her fall. LN stated staff S2 was also standing in the immediate area and witnessed the incident.

LN stated once R1 was on the ground, he/she did not make any comments or complaints of any pain. LN stated staff assisted R1 up and R1 walked as he/she always did for the remainder of the day. LN denies that R1 and R2 were unsupervised. LN stated R1 walked with a gain, used a cane and had one “stiff” leg.

On December 21, 2022, the Department interviewed staff S1. S1 confirmed he/she was present during the incident involving resident R1 and R2 on September 6, 2022. S1 stated S2 was standing next to R1 when he/she was pushed. S1 stated R1 was assigned to S2’s group that day.

S1 stated the incident occurred at approximately 9:30am-10:00am, which is snack time at the day program. S1 stated the incident occurred right in front of the water fountains, which are located in the center of the day room. S1 stated he/she didn’t observe R2 push R1, but did hear staff call out for assistance and he/she immediately responded to the area. S1 observed R1 on the ground and R2 nearby. S1 stated, staff S2 and LN told S1 that R2 had suddenly pushed R1 causing him/her to fall. S1 stated R1 was helped up by staff and R1 did not complain of any pain or discomfort. S1 stated R1 got up and seemed fine the rest of his/her stay on September 6, 2022. R1 did mildly complain of hip and leg pain, but he/she was known already to do so. S1 stated the following morning, R1 was dropped off. R1 was walking by R2 and he/she “buckled” and began to fall. S1 was able to catch R1 before he/she fell onto the ground. R1 told S1 he/she was in pain and 911 was contacted.

S1 stated R1 had an unsteady gait and walked with a cane. S1 reported R1 and R2 did not have any type of verbal confrontation or disagreement prior to the incident. S1 stated they do not have a history of not getting along. S1 denied R2 showing any type of anger towards anyone before pushing R1. S1 stated “he/she just pushed him/her out of the blue.”

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 11/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20220912093104
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: MARANATHA DAY PROGRAM
FACILITY NUMBER: 374604331
VISIT DATE: 12/08/2025
NARRATIVE
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The Department interviewed Staff S2. S2 confirmed he/she was present on September 6, 2022, when the incident between R1 and R2 occurred. S2 stated he/she was standing by both residents near the water fountains inside the day program, when suddenly and unprovoked R2 pushed R1 as he/she was slowly walking by. S2 stated R1 was left on the ground for five to seven minutes for him/her to gather him/herself and an assessment. S2 stated R1 did not complain of any pain or say he/she was hurt. S2 stated after a few minutes, R1 was helped up by staff and R1 went about his/her day as normal. S2 stated the follow day, shortly after arriving, R1 stated his/her leg was hurting and 911 was contacted.

S2 stated R2 will sometimes push people as they walked by but would not push with any great force. S2 stated R2 has occasionally taken a “swipe” at other residents and has hit staff before, but this was the first time R2 has cause a significant push to a resident. S2 stated R1 already used a cane due to a previous hip issue and had a gait. S2 denied there was any confrontation between R1 and R2 before the incident. S2 stated there was no history of animosity between both residents.

The Department reviewed Resident R2’s Individual Program Plan (IPP), dated March 16, 2020. R2’s IPP, page 3 states, R2 requires behavioral support in regarding to physical aggression, non compliance, self injurious behaviors (SIB), verbal aggression/curing and inappropriate boundaries. Most of R2’s behaviors occur in the morning. R2’s IPP also states R2’s physical aggression/ SIB is not severe. R2 will slap or pull hair on occasion.

Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegation as UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegation did or did not occur.

This Report was reviewed with Administrator Nicole Guibert. LPA Monter informed Administrator Nicole Guibert that a PDF copy of the signed report by LPA Monter will be emailed to ADM's for her signature and a signed copy returned to LPA Monter. ADM stated she will send the signed original report to the San Diego Regional Office.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 11/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3