374604700-3-21-2025-08-AS-SJAB-DF7QUY-20250328122931

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604700
Report Date: 03/21/2025
Date Signed: 03/21/2025 05:07:41 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
01/23/2025 and conducted by Evaluator Marisela Garcia-Centeno

COMPLAINT CONTROL NUMBER: 08-AS-20250123152905

FACILITY NAME:	INDAYPROGRAMSAC		FACILITY NUMBER:	374604700
ADMINISTRATOR:	MARZEENA, NORA		FACILITY TYPE:	775
ADDRESS:	615 E LEXINGTON AVE		TELEPHONE:	(619) 995-3543
CITY:	EL CAJON	STATE: CA	ZIP CODE:	92020
CAPACITY:	60	CENSUS: 21	DATE:	03/21/2025
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Administrator, Nora Marzeena		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not provide a safe environment for client
Staff did not follow reporting requirements

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced complaint visit to deliver investigative findings. LPA met with Administrator Nora Marzeena and shared the findings.

The Department investigated the above-listed complaint allegations. The investigation included observations, a review of relevant records, and interviews with facility staff and outside sources.

On January 23, 2025, Community Care Licensing (CCL) received a complaint alleging that staff did not provide a safe environment for Client 1 (C1). [staff were provided the LIC811 confidential names list to identify the client (C1). It was specifically alleged that during group activities, C1 was placed with clients who exhibited aggressive behaviors and that staff failed to provide proper supervision to ensure C1’s safety.

(Continue at LIC9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2025

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 3

Control Number 08-AS-20250123152905

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: INDAYPROGRAMSAC	FACILITY NUMBER: 374604700
	VISIT DATE: 03/21/2025

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

(continue from LIC9099)

The complaint further alleged that other clients would hit and pull C1’s hair, take away C1’s personal belongings, and that staff failed to take corrective or preventive measures to protect C1 from harm. Additionally, it was alledged that clients with aggressive behaviors took advantage of C1, who was described as friendly, calm, and easygoing.

An interview with an outside source revealed that they had not personally witnessed any incidents of abuse; rather, they became aware of the allegation through hearsay. Furthermore, no specific details regarding the alleged incidents were disclosed during the investigation. C1 was not available for an interview as they were no longer attending the day program.

On January 29, 2025, during a facility tour, clients were observed participating in group activities in groups of four (4) to five (5), with two (2) staff members supervising and guiding the activities. Clients appeared engaged and followed staff directions. Staff members were observed redirecting clients back to their activities when they stood up or wandered away from the table.

As part of the investigation, images and videos were submitted as evidence of the alleged abuse. A thorough review of the provided materials did not reveal any corroborating evidence to support the allegation that staff failed to provide a safe environment. Instead, the images and videos depicted clients participating in activities at the park and the facility, with no observed violations of personal rights or indications of physical abuse.

During staff interviews, it was consistently stated that clients were placed in groups with others who were behaviorally compatible. Staff reported that any clients displaying aggressive behavior were immediately redirected and, if necessary, removed from the group. Furthermore, staff consistently denied witnessing any mistreatment or physical abuse among clients or by staff members.

A detailed review of staff training records confirmed that all staff had completed the required training per Title 22 regulations, including personal rights, de-escalation techniques, and reporting requirements. Additionally, staff received specialized training on crossing streets with clients, boarding and unloading the facility van, seat belt requirements, and walking in public places such as parks, libraries, and malls.

(Continue at LIC9099C)

SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 08-AS-20250123152905

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: INDAYPROGRAMSAC	FACILITY NUMBER: 374604700
	VISIT DATE: 03/21/2025

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

(Continue from LIC9099C)

The facility also implemented measures to maintain a safe environment, ensuring that all walkways were kept clear of clutter and that backpacks were stored out of sight to prevent falls.

The complaint also alleged that staff failed to follow reporting requirements, specifically regarding an incident in early November 2024, in which C1 allegedly sustained a fall. It was reported that an outside source observed a rug burn on C1’s knee along with a small skin tear and stated that staff did not report the incident to the responsible party. In addition, during the visit, the facility was observed that there were no rugs where C1 could have sustained the rug burn injury.

However, multiple interviews with staff and outside sources did not provide any corroborating evidence to support this allegation. Staff and outside sources consistently indicated that they did not witness C1 falling at the facility. During interviews, staff stated that the facility had a strict policy requiring immediate reporting of any client injury to management to ensure timely medical attention and compliance with Title 22 reporting requirements.

After a comprehensive investigation, including staff and client interviews, a review of records, and interviews with outside sources, the Department determined that the preponderance of evidence does not support the allegations. Therefore, the allegations are deemed unsubstantiated.

An exit interview was conducted with Administrator Nora Marzeena, who was provided with a copy of this report, the LIC811 Confidential Name List form and the Licensee Appeal Rights (LIC9058 03/22) at the conclusion of the visit.

SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 3