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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604344
Report Date: 01/23/2026
Date Signed: 01/27/2026 11:10:35 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
01/20/2026 and conducted by Evaluator Amy Domingo
COMPLAINT CONTROL NUMBER: 08-AS-20260120144402
FACILITY NAME:JIMENEZ HOMES ARF LLCFACILITY NUMBER:
374604344
ADMINISTRATOR:JIMENEZ, ERICKA D.FACILITY TYPE:
735
ADDRESS:1707 SKYLINE DRIVETELEPHONE:
(619) 987-2558
CITY:LEMON GROVESTATE: CAZIP CODE:
91945
CAPACITY:4CENSUS: 4DATE:
01/23/2026
UNANNOUNCEDTIME BEGAN:
08:28 AM
MET WITH:Cynthia Vasquez & Ericka Jimenez, Administrators TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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The Resident was given unprescribed medication
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to initiate an investigation on the above-mentioned allegations. LPA identified herself and discussed the purpose of the visit with Cythia Vasquez and later Ericka Jimenez, Administrator.

On January 20, 2026, Community Care Licensing (CCL) received a complaint alleging a resident was given unprescribed medication. During the investigation, LPA Domingo collected pertinent resident records as well as facility documentation and conducted interviews with residents and staff.

According to allegation, the staff was giving the day program a bag of white powder to thicken Resident 1's (R1's) drinks. The day program stated that they could not thicken R1's drinks without an order.


Continued on LIC9099C

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2026
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 2
Control Number 08-AS-20260120144402
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: JIMENEZ HOMES ARF LLC
FACILITY NUMBER: 374604344
VISIT DATE: 01/23/2026
NARRATIVE
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Continued from LIC9099

Staff 1 was interviewed and S1 provided a list of prescribed medication with individual packets with the thicken agent that was marked with the type of thicken agent and how the agent to be used which has the the physician's order. S1 stated they do not given any medications or thickening agents without an order. Staff 2 was interviewed and S2 stated that they provided the day program with the label from the container that had the directions on how to mix the thicken agent to liquids as need for R1. Outside Source 1 (OS1), stated to the facility staff they needed an order to give the thicken agent to R1. S1 and S2 verified with OS1 that there was a physician's order. S1 and S2 stated that the facility would not provide medication or a thickening agent without an order.

Interview with Outside Source 2 (OS2) verified that the facility provides physician's orders for any medications that need to be given during the day program. OS2 stated that there has not been any issues with providing a physician's order.

Records reviewed revealed a valid order for R1 to have a thicken agent as needed for liquids. R1 is currently not participating in the day program. S1 and S2 stated they have been providing the physician's order for all medications and thickening agent to the day program.

Based on LPA's interviews, observations and record reviews there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegation is unsubstantiated. An exit interview was conducted with Cynthia Vasquez and Ericka Jimenez, Administrators, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2