<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604547
Report Date: 09/10/2025
Date Signed: 09/10/2025 10:57:18 AM

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
06/18/2024 and conducted by Evaluator Tiffany Holmes
COMPLAINT CONTROL NUMBER: 08-AS-20240618134645
FACILITY NAME:L & M RESIDENTIAL #2FACILITY NUMBER:
374604547
ADMINISTRATOR:LARA, OSCARFACILITY TYPE:
735
ADDRESS:9028 DAVENRICH ST.TELEPHONE:
(619) 778-8949
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY:4CENSUS: 3DATE:
09/10/2025
UNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Vanessa Martinez- Ledesma, Staff
Oscar Lara, Administrator		TIME COMPLETED:
11:05 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Neglect/Lack of Supervision resulting in delayed medical care
Licensee did not meet incident reporting requirements
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced visit to deliver findings for a complaint investigation regarding the above-mentioned allegations. LPA identified herself and met with Oscar Lara, Administrator, to discuss the purpose of the visit and elements of the complaint.

The Department's investigation included interviews and a review of pertinent records. It was alleged that neglect/lack of supervision resulting in delayed medical care.

Interviews revealed that Client 1 (C1) was first admitted to L & M Residential in August of 2022. A review of Client 1's physician's report dated 03/08/2022 revealed that C1 has a diagnosis of Profound Mental Retardation (ID), Cerebral Palsy and Epilepsy.
Interviews revealed that C1 is ambulatory but isn’t completely steady on their feet. Interviews with staff revealed during the last year and a half C1 has lived at the facility, they have had multiple seizures that vary from being minor to severe seizures. Interviews revealed that when C1 has a minor seizure that lasts only a couple of minutes, C1 can bounce back quickly but if it is a severe seizure C1 becomes weak and falls asleep the rest of the day.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2025
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-20240618134645
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: L & M RESIDENTIAL #2
FACILITY NUMBER: 374604547
VISIT DATE: 09/10/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Interviews revealed that a major seizure is one that lasts about 15 minutes or longer which C1 will require a rescue medication. A rescue medication is a nasal spray called Nayzilam that helps stop the seizures. Interviews revealed that any four or more seizures lasting four minutes each will require the client to take the rescue medication.

Interviews with staff revealed there is a certain protocol the facility follows when a client has a seizure. When a client has a seizure, they will keep them on the floor and get them comfortable with blankets and pillows until their episode ends. Interviews revealed that during the time the client is on the floor, they are monitoring the time of the seizures and counting them to make sure no rescue medication is needed. Interviews revealed that typically the client will stay on the floor for at least 30 minutes before staff help them up and escort them to their bed. Interviews revealed the staff know never to let the client get up and walk on their own after a seizure. Interviews revealed on 06/09/2024, C1s family member came to pick up C1 for the day and returned later that day. Interviews revealed on 06/11/2024, staff found C1 on the floor after dinner around 7:00 pm. Staff began to do what they are trained to do, which is leave the client on the floor, clear their surroundings and make C1 as comfortable as possible and monitor their seizure. C1 had three little seizures, and no rescue medication was administered since the seizures were each less than two minutes. Interviews revealed staff waited about half an hour before they got C1 up from the floor and put them into a wheelchair, and escorted them to bed around 8:00 pm. Interviews revealed that staff changed C1’s diaper while assessing C1 from head to toe, moving all their joints and there were no signs of visible injuries or bruising. On 06/12/2024, C1s family member came to the facility around 8:30 am and they observed C1 wasn’t up yet. Interviews revealed that the lead staff arrived at the facility around 9:30 am, and they went to check on C1. Interviews with lead staff revealed that they assessed C1 to see if any bruising appeared overnight and they did not observe any visible injuries or bruising on C1.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 08-AS-20240618134645
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: L & M RESIDENTIAL #2
FACILITY NUMBER: 374604547
VISIT DATE: 09/10/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Interviews revealed that C1 was still a bit weak and did not want to stand up on their own so after changing C1s diaper and getting them ready, staff placed C1 back in the wheelchair and escorted C1 to the living room. Interviews with an outside source revealed that on 06/12/2024, they arrived at the facility to see C1 in a wheelchair and unable to walk. The outside source called 911, and C1 was transported to the hospital, where records state C1 sustained a left hip fracture, which required surgery. Observation of photos that were provided of C1s hips and legs on the morning of 06/12/2024, do not show any obvious signs of injuries but they are not clear enough to observe injury or visible swelling. The facility appeared to respond to C1’s seizure and the first 14 hours after the seizure appropriately; however, on the morning of 06/12/2024 at 9:30 am, during the staff’s assessment of C1, it was apparent C1 was not acting like them self and was unable to stand on their own like usual. In addition, according to the ambulance records that revealed upon arrival, “the Patients left leg is swollen at the thigh and patient's hip appears to be dislocated”.

It was alleged that the licensee did not meet incident reporting requirements. Interviews with an outside source revealed the facility did not report the incident after the client had their seizure on 06/11/2024. Interviews revealed there weren't any incident reports provided to San Diego Regional Center (SDRC) or to CCL to report. Interviews also revealed the day C1 went to the hospital on 06/12/2024 the facility did not report that incident either.

An exit interview was conducted with Oscar Lara, a Plan of Correction was developed. A copy of this report, Licensee Rights (LIC 9058 03/22) and copies of pertinent Title 22 Regulations, were provided to the Administrator Lara and their signature on this form confirms receipt of the document.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Citations on this Visit Report are Under Appeal!

Control Number 08-AS-20240618134645
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: L & M RESIDENTIAL #2
FACILITY NUMBER: 374604547
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/03/2025
Section Cited
CCR
80078(a)
1
2
3
4
5
6
7
Responsibility for Providing Care and Supervision
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
Licensee will contact Jewish Families Services to have them do a training on Responsibility for Providing Care and Supervision for all staff. POC due by 10/03/2025. Licensee will submit POC and sign in sheet with training materials to CCL by 10/03/2025
8
9
10
11
12
13
14
Based on observation, records, and interviews, the licensee failed to provide supervision and call 911 to ensure 1 out of 4 (C1) received timely medical attention. This poses an immediate risk to residents in care.

8
9
10
11
12
13
14
Under Appeal
Type B
09/26/2025
Section Cited
CCR
80061(a)(b)(2)
1
2
3
4
5
6
7
Each licensee or applicant shall furnish to the licensing agency reports as required by the Department, including, but not limited to, those specified in this section.
Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2)below shall be submitted to the licensing agency within seven days following the occurrence of such event. This requirement was not met, as evidenced by:

1
2
3
4
5
6
7
Licensee will contact Jewish Families Services to have them do a training on Incident reporting for all staff. POC due by 10/03/2025.Licensee will submit POC and sign in sheet with training materials to CCL by 10/03/2025
8
9
10
11
12
13
14
Based on observation, records, and interviews, Licensee did not complete an incident report for 1 of 4 clients. (C1) had a seizure on 06/11/24 which resulted in C1 going to the hospital on 06/12/24 which posed a possible health risk to persons in care.
8
9
10
11
12
13
14
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: 09/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4