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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604686
Report Date: 05/23/2025
Date Signed: 05/23/2025 03:08:43 PM

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
10/30/2024 and conducted by Evaluator Tiffany Holmes
COMPLAINT CONTROL NUMBER: 08-AS-20241030140139
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: 3DATE:
05/23/2025
UNANNOUNCEDTIME BEGAN:
02:52 PM
MET WITH:Carson Spivey, AdministratorTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Neglect/Lack of Supervision resulted in resident on resident assault
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA)Tiffany Holmes conducted an unannounced complaint visit to the facility to close a complaint on the above-mentioned allegation. LPA gained access to the facility, identified herself, and met with Carson Spivey, Administrator.

During the visit, LPA toured the facility, reviewed and obtained copies of facility records. It was alleged that neglect/Lack of Supervision resulted in resident on resident assault. Interviews revealed that Client 1s (C1) antecedents are self injurious behaviors and a few pre cursors are that they pick their face, or rubs it aggressively or they will pick their toenails off. Interviews revealed that C1 will go back and forth, wash their face profusely and this is where staff feel the bruising is coming from. Interviews revealed the bruising was on C1s forehead and under their eyes which is where C1 aggressively wipes their face several times a day.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2025
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 2
Control Number 08-AS-20241030140139
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: 05/23/2025
NARRATIVE
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According to C1s Individual Program Plan (IPP) it stated that C1 has maladaptive behaviors and requires a higher level of care to keep them safe. C1 is typically physically aggressive towards staff and other clients. C1 has a diagnosis of Intellectual disability and Autism Spectrum Disorder.

Interviews revealed that on this day C1 started going back and forth and up and down the stairs going into the bathrooms. C1 then went back upstairs and according to interviews revealed they attacked Staff 1 (S1). Interviews revealed that after C1 attacked S1, the other staff were able to verbally de-escalate C1 and then the licensee was called and they arrived shortly after. Interviews revealed by the time the licensee was called C1 was calm. Interviews revealed that the bruises were already there on C1s face prior to C1 attacking staff. According to staff interviews the administrator and C1's mom are their triggers which C1 obsesses over the administrator and their mom. Interviews revealed that PERT was called and hey took C1 to the hospital for a 51/50 hold. Interviews revealed that on the date of this incident that C1 got physical with the licensee, attacked 1 client and one staff. There were no complaints from outside sources on the staff not neglecting the clients or any type of lack of supervision.

There was no supporting witness statements to substantiate neglect/Lack of Supervision resulted in resident on resident assault therefore the allegation is unsubstantiated.

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

DATE: 05/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2