374604446-2-6-2025-08-AS-SJAB-DE8NZ3-20250225095337

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604446
Report Date: 02/06/2025
Date Signed: 02/06/2025 06:05:53 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
01/28/2025 and conducted by Evaluator Dang Nguyen

COMPLAINT CONTROL NUMBER: 08-AS-20250128153352

FACILITY NAME:	ABIGAIL'S HOMES IV		FACILITY NUMBER:	374604446
ADMINISTRATOR:	GONZALEZ, BRENDA A		FACILITY TYPE:	735
ADDRESS:	1066 MOUNT DANA DRIVE		TELEPHONE:	(619) 315-7407
CITY:	CHULA VISTA	STATE: CA	ZIP CODE:	91913
CAPACITY:	4	CENSUS: 4	DATE:	02/06/2025
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	House Manager Omar Corona		TIME COMPLETED:	06:15 PM

ALLEGATION(S):

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Absence of client supervision, contributing to elopement.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced visit to commence a Complaint Investigation regarding the above allegation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with House Manager Omar Corona.

The Complainant alleged that for a short period on 01/27/2025, Licensee’s staff left Client #1 (C1) unsupervised in a parked vehicle, which contributed to C1’s elopement (i.e., C1 left and became missing until police found them). [See LIC 811 Confidential Names List for a description of person identifiers used in this report.] CCLD’s investigation involved an unannounced facility tour/welfare check and interviews of C1 and all relevant housemates and facility staff. The Department also reviewed pertinent police reports and care records, as well as the Special Incident Report which Licensee had prior-submitted to CCLD for the incident.

[CONTINUED ON LIC 9099-C, 1 of 2]

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2025

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 4

Control Number 08-AS-20250128153352

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ABIGAIL'S HOMES IV	FACILITY NUMBER: 374604446
	VISIT DATE: 02/06/2025

NARRATIVE

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[CONTINUED FROM LIC 9099]

According to staff interviews and care records from San Diego Regional Center (SDRC), C1 was diagnosed with Mild Intellectual Disability and was not able to safely leave the facility unassisted. Per C1’s SDRC Client Placement Referral, a document in licensee’s possession, C1 had one elopement incident prior to moving-in to Abigail’s Home IV in May 2022. Staff interviews showed C1 eloped on a few occasions during their first year living at the facility, requiring police involvement for some. C1’s exit-seeking behavior then mostly subsided, until the two (2) days leading up to the current incident in question, during which time C1 was yelling/cursing at staff, punching walls, throwing objects, and stating that they wanted to leave.

Staff interviews and police records generally aligned to show: On the afternoon of 01/27/2025, Staff #1 (S1) and Staff #2 (S2) transported C1, Client #2 (C2), Client #3 (C3), and Client #4 (C4) via passenger van to a medical office. Once parked, S2 walked/escorted C4 inside the medical office for their doctor’s appointment and remained with them. Meanwhile, S1 stayed in the vehicle with C1, C2, and C3. About an hour later, C1 began punching/kicking the seat of C2 and yelling. Seeking to minimize the impact of these behaviors, S1 walked/escorted C2 and C3 into the medical office so that they could be left with S2. However, in the process S1 left C1 alone inside the vehicle. (The doctor’s office was roughly fifty yards from where the vehicle was parked, but due to a bend/turn was also not in direct line-of-sight of the vehicle.)

Once inside the medical office, S1 and S2 spent several minutes conversing. Staff accounts of how long S1 was away from the vehicle (and C1) ranged from “five to ten minutes” to “eight to ten minutes." When S1 returned to the vehicle, C1 was no longer there. Staff searched the parking lot and nearby premises for about twenty minutes, then called 911 around 5:45 PM. Chula Vista Police Department (CVPD) conducted a full search for C1, employing public announcements and air support. Shortly after 8:30 PM, C1 approached Southwestern College Police Department (SDCPD) personnel to ask them for help getting home. C1 had traveled around 5.4 miles on foot by the time they were found. C1 was unharmed and uninjured, and facility staff went to collect C1 and bring them back to the facility.

[CONTINUED ON LIC 9099-C, 2 of 2]

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 08-AS-20250128153352

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ABIGAIL'S HOMES IV	FACILITY NUMBER: 374604446
	VISIT DATE: 02/06/2025

NARRATIVE

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[CONTINUED FROM LIC 9099-C, 1 of 2]

Based on records and interviews, a preponderance of evidence exists supporting Licensee’s absence of supervision during the incident, contributing to C1’s elopement. The allegation is therefore Substantiated. One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the LIC 9099-D page). Since the violation relates to Absence of Supervision, an Immediate Civil Penalty of $500.00 was also assessed/charged (refer to the LIC421-IM page). A Plan of Correction was jointly developed with the Licensee.

An exit interview was conducted with House Manager Omar Corona, to whom a copy of this report, the LIC 9099-D page, the LIC421-IM page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 08-AS-20250128153352

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ABIGAIL'S HOMES IV	FACILITY NUMBER: 374604446
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/06/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/06/2025 Section Cited CCR 80078(a)	1 2 3 4 5 6 7	80078 Responsibility for Providing Care and Supervision: “(a) The licensee shall provide care and supervision as necessary to meet the client’s needs.” This requirement was not met, as evidenced by:	1 2 3 4 5 6 7	C1 was located safe later the same day, and returned to the care and supervision of staff, resolving the immediate risk. Licensee agreed to conduct training with all current staff to debrief about the incident and the lessons learned from it. Licensee also agreed to install auditory alert devices on each of its perimeter exit doors. Licensee agreed to transmit to LPA a copy of the training sign-in sheet and videos of the door chimes in action, by 02/28/2025.
	8 9 10 11 12 13 14	Based on records and interviews, during the incident in question, Licensee did not provide care and supervision necessary to meet the needs of 1 of 4 clients (C1), which posed an immediate safety risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2025

LIC9099 (FAS) - (06/04)

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