374604411-5-21-2026-08-AS-APAO-DUBW2Z-20260522165511

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604411
Report Date: 05/21/2026
Date Signed: 05/21/2026 09:56:14 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
08/27/2024 and conducted by Evaluator Ramin Hashemi

COMPLAINT CONTROL NUMBER: 08-AS-20240827162536

FACILITY NAME:	LA MAREA SENIOR LIVING		FACILITY NUMBER:	374604411
ADMINISTRATOR:	GREGORY CASE		FACILITY TYPE:	740
ADDRESS:	5592 EL CAMINO REAL		TELEPHONE:	(442) 325-3510
CITY:	CARLSBAD	STATE: CA	ZIP CODE:	92008
CAPACITY:	125	CENSUS: 109	DATE:	05/21/2026
		UNANNOUNCED	TIME BEGAN:	08:35 AM
MET WITH:	Executive DIrector Mariano Perez		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Staff did not notify authorized representative of incident
Residents are not treated with dignity and respect

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ramin Hashemi conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Executive DIrector Mariano Perez.

On 08/27/2024 it was alleged that "Staff did not notify authorized representative of incident" The Department’s investigation consisted of unannounced facility visits, interviews with facility staff and residents, and records review.

Regarding the allegation, "Staff did not notify authorized representative of incident," it was alleged that Resident 1 (R1) received a serious injury and the responsible party (RP)/Power of Attorney (POA) was not notified per licensing requirements.

(Continued on LIC9099C, Page 2)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Ramin Hashemi
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2026

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-20240827162536

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: LA MAREA SENIOR LIVING	FACILITY NUMBER: 374604411
	VISIT DATE: 05/21/2026

NARRATIVE

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(Continued from LIC9099, Page 1)

Interviews with facility staff revealed that facility staff unanimously could not state to the LPA how the resident received the injury almost two years ago to the date of the initial complaint, who treated it at the time, and whether or not it was reported to the POA. All interviewed staff agreed that the preferences of reporting incident reports and other reportable events to the POA for R1 were to be communicated by phone when the POA was not at the facility visiting R1. Facility staff agreed that most reports were communicated verbally when the POA would visit on a daily basis.

Records Review revealed that the staff were aware of the injury. Care notes from the facility dated on 07/11/2024 at 1:56 AM stated, "Resident has a skin tear on their left shin. Medtech cleaned the area and put on a large band aid." In an email sent directly to facility staff about R1's care from the POA, it was stated that they were never notified through phone that R1 received the injury on their lower left extremity nor was the POA emailed a response by facility staff. In several other emails sent to the LPA by the POA of their conversations with the facility, it was stated that the POA visited R1 on a daily basis almost without fail and received verbal updates from staff in addition to phone calls.

The regulation of CCR Title 22 87211 Reporting requirements states that a written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D); (B) Serious injury as determined by the attending physician and occurring while the resident is under facility supervision. Welfare and Institutions Code Section 15610.67 provides: “Serious bodily injury” means an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including, but not limited to, hospitalization, surgery, or physical rehabilitation. The skin tear injury that R1 sustained does not fall under this definition and is not considered a serious injury and was not required by licensing requirements to be reported to CCLD offices or to the representative.

Based on interviews, direct LPA observations and records review, a preponderance of evidence does exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED.

(Continued on LIC9099C, Page 3)

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Ramin Hashemi
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 2

Control Number 08-AS-20240827162536

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: LA MAREA SENIOR LIVING	FACILITY NUMBER: 374604411
	VISIT DATE: 05/21/2026

NARRATIVE

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(Continued from LIC9099C, Page 2)

On 08/27/2024 it was alleged that "Residents are not treated with dignity and respect" The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review.

Regarding the allegation, "Residents are not treated with dignity and respect," it was alleged that facility staff taunt and act malicious towards R1.

Interviews with staff revealed that staff unanimously did not witness other facility staff members acting malicious towards R1 or treating R1 without dignity and respect. Staff unanimously described R1 as a "sweet resident" who was often in pain and would become agitated during care due to their pain and sensitivity threshold. Caregivers and medical technicians encouraged other staff to seek help and avoid situations of being alone when R1 became aggressive. Multiple interviews with facility staff indicated srhey were concerned with R1's family interfering with R1's care and personal rights by denying the resident their rights to refuse medication and to have a schedule that reflected their wants and desires. An example provided by the POA to the LPA of lack of dignity and respect included a picture of R1's toes exposed through a purposefully cut and manicured sock. Facility staff unanimously told the LPA that this was due to R1's documented complaint of sensitivity and pain especially in their toes and feet. In this instance, the facility was responding to R1's needs and did not perform this act with malicious intent.

Interviews with residents revealed that residents have not witnessed malicious acts from staff towards residents or that residents are not treated with dignity and respect per CCLD guidelines.

Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Executive Director Mariano Perez, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Ramin Hashemi
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2026

LIC9099 (FAS) - (06/04)

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