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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604686
Report Date: 07/16/2024
Date Signed: 07/16/2024 04:46:50 PM

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
07/08/2024 and conducted by Evaluator Tiffany Holmes
COMPLAINT CONTROL NUMBER: 08-AS-20240708114830
FACILITY NAME:4 PILLARS CARE LLCFACILITY NUMBER:
374604686
ADMINISTRATOR:MOALA, JOSHUAFACILITY TYPE:
735
ADDRESS:1641 CUYAMACA AVE.TELEPHONE:
(619) 834-9680
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY:4CENSUS: 4DATE:
07/16/2024
UNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Giovanni Marquez, Staff &
Licensee Carson Spivey		TIME COMPLETED:
02:50 PM
ALLEGATION(S):
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Staff did not provide adequate supervision resulting in residents engaging in a physical altercation while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA)Tiffany Holmes conducted an unannounced complaint visit to the facility to open a complaint on the above-mentioned allegation. LPA gained access to the facility, identified herself, and met with Giovanni Marquez, Staff to discuss the purpose of the visit. Licensee Carson Spivey arrived during the visit.

During the visit, LPA toured the facility, reviewed and obtained copies of facility records. It was alleged that staff did not provide adequate supervision resulting in residents engaging in a physical altercation while in care. Interviews revealed that on July 07, 2024 there were two staff at the facility from the morning shift and transitioning to the evening staff and at the time the incident occurred there was only one staff on shift. The staff was in eyesight of the clients when the incident took place. Interviews revealed Client 2 (C2) was on the phone in the living room and Client 1 (C1) wanted to use the phone.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024
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-20240708114830
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: 4 PILLARS CARE LLC
FACILITY NUMBER: 374604686
VISIT DATE: 07/16/2024
NARRATIVE
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C1 got upset that C2 was on the phone and went into the living room and tried to take the phone away and started to hit, kick and choke C2. Interviews revealed the staff was able to intervene and separated the two clients. Interviews revealed C1 moved away from staff, and grabbed C2 and bit C2 on the side of their face and on the neck. Interviews revealed there the bite marks were noticeable. Interviews revealed the paramedics were called and once they arrived they evaluated C2 for injuries and wanted them to go to the hospital so they transported C2 to the hospital for an evaluation and treatment. Interviews revealed C1 was removed from the facility by the sheriffs department the same day and was put on a 5150 hold for being a danger to others. C2 stayed at the hospital for one day and returned back to the facility.

Interviews revealed the other staff was running late on this day and once they arrived the emergency personnel had already left with C2 and C1 was in the back of the sheriffs car. The licensee and administrator both were called and the incident took place while the administrator was on the phone with the staff while C2 called 911.

There was supporting witness statements to substantiate staff did not provide adequate supervision resulting in residents engaging in a physical altercation while in care.

An exit interview was conducted with Licensee Carson Spivey. A copy of this report and the Licensee's Rights (LIC9058 03/22) were provided to Licensee at the end of the visit.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20240708114830
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: 4 PILLARS CARE LLC
FACILITY NUMBER: 374604686
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/02/2024
Section Cited
CCR
80078(a)
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80078 Responsibility for Providing Care and Supervision: Responsibility for Providing Care and Supervision. The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement is not met as evidenced by:
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Licensee stated they will attend training along with staff regarding client supervision & how to de-escalate clients and provide proof of training and sign in sheet by POC due date of 8/2/2024
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Based on interviews and record the licensee did not provide supervision for 2 out of four clients by having only 1 staff This posed a potential health and safety risk to clients in care.
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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: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3