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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604686
Report Date: 11/14/2024
Date Signed: 11/14/2024 01:29:06 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
11/13/2024 and conducted by Evaluator Tiffany Holmes
COMPLAINT CONTROL NUMBER: 08-AS-20241113145304
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:
11/14/2024
UNANNOUNCEDTIME BEGAN:
12:49 PM
MET WITH:Joshua Moala, AdministratorTIME COMPLETED:
01:36 PM
ALLEGATION(S):
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Facility does not maintain client records
Staff did not meet training requirements
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced investigation visit to open a complaint investigation regarding the above mentioned allegation. LPA was greeted by, identified herself to, and explained the purpose of the visit and the basic elements of the complaint with Joshua Moala, Administrator.

During the visit, LPA toured the facility, reviewed and obtained copies of facility records. It was alleged that the facility does not maintain client records. Interviews with outside sources revealed that there were two client files that were reviewed and the files were incomplete and missing required documents. An outside source completed a review of the medication administration records (MAR) both clients revealed missing signatures for staff administering the medications for at least one medication. Interviews revealed the signature was not on the MAR due to client going to the hosital and the staff did not mark hospital visit. Lastly, interviews revealed that P&I records were reviewed for the same two resident files and both files did not contain a P&I ledger documenting the receipt and transfer of P&I funds from the licensee to both clients. Interviews with staff revealed the clients use debit cards but admitted that the amount left in the account is not documented on the P&I ledger.


Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
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-20241113145304
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: 11/14/2024
NARRATIVE
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It was alleged that the staff did not meet training requirements. Interviews with outside sources revealed both reviewed files did not contain evidence a current CPR/First Aid certifications. Interviews with staff revealed they requested it at everyone's onboarding at hire but they did not follow through with getting them from the new hires.

There was supporting witness statements to substantiate facility does not maintain client records and staff did not meet training requirements

An exit interview was conducted with Joshua Moala, Administrator . 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: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20241113145304
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: 11/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/05/2024
Section Cited
CCR
80070(a)
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The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client. This requirment is not met as evidenced by:
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Licensee will complete P&I ledgers and submit them to ccl via email. Licensee will also start keeping cash on hand for the clients instead of all the monies being on debit cards.
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Based on interviews and the record review the licensee did not have have up to date ledgers, 2 signatures on Mars and incomplete SIRs for 2 out of 4 clients . This posed a potential health and safety risk to clients in care.
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Licensee will also conduct a training on P&I and Mars training with SDRC and come back and train their staff. Licensee will submit all training, sign in sheets and paperwork to CCLby POC due by 12/05/2024
Type B
12/05/2024
Section Cited
CCR
80075(f)
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Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross. This requirement was not met as evidenced by:
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Licensee will look through the other staff files and have all staff plus the two that did not have their first aid certificate complete the training by December 5 2024.POC due to CCL by 12/05/2024. Licensee will send over the certificates via email
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Based on interviews and records the licensee did not have 1st aid certificates for 2 out of eight 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: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3