374604751-3-26-2026-08-AS-SJAB-DSSUTN-20260403155213

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604751
Report Date: 03/26/2026
Date Signed: 03/26/2026 03:16:51 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
12/05/2025 and conducted by Evaluator Tiffany Holmes

COMPLAINT CONTROL NUMBER: 08-AS-20251205123548

FACILITY NAME:	NANCY VASQUEZ RESIDENTIAL CARE CENTER		FACILITY NUMBER:	374604751
ADMINISTRATOR:	CURTIS, PHILIP C.		FACILITY TYPE:	735
ADDRESS:	8627 TROY STREET		TELEPHONE:	(619) 754-5250
CITY:	SPRING VALLEY	STATE: CA	ZIP CODE:	91977
CAPACITY:	42	CENSUS: 41	DATE:	03/26/2026
		UNANNOUNCED	TIME BEGAN:	01:35 PM
MET WITH:	Nick Fierro, Program Manager		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Neglect to client resulting in serious bodily injury
Staff mishandled a client's medication

INVESTIGATION FINDINGS:

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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 Nick Fierro, Administrator, to discuss the purpose of the visit and elements of the complaint.

The Department's investigation included interviews with residents, staff, and outside sources and a review of pertinent records. LPA Rodgers conducted the initial visit on 12/08/2025 and conducted a tour of the facility. It was alleged that Neglect to client resulting in serious bodily injury.

Client 1 (C1) is diagnosed with Schizophrenia and Bipolar. C1 is prescribed 450 mg (milligram) of Clozapine for a Schizophrenia diagnosis that C1 takes every evening before bed. Interviews revealed that this medication helps lessen delusions, hearing voices, and allows C1 to sleep better at night. Interviews revealed on 12/4/2025, C1 was seen on the second story roof at Nancy Vasquez Residential Care Center by Staff 1 (S1). S1 was able to convince C1 to climb down from the roof to S1s location. Interviews revealed that S1 did not immediately call 911 to have C1 evaluated and did not notify other staff or the on-duty supervisor for assistance to get C1 medical or psychiatric aid. S1 escorted C1 to the dining/medication room and asked C1 to stay in the room until S1 finished passing out medications to other residents. Interviews revealed that S1 got busy losing track of C1 and they went back upstairs to their room, climbed out the window to the second-story roof, and jumped headfirst to the pavement below. Interviews revealed C1 was hospitalized and diagnosed with a large laceration on their head, broken ribs, and a spine fracture. Based on the investigation, the preponderance of the evidence standard has been met and the allegation of Neglect to client resulting in serious bodily injury is substantiated.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:	DATE: 03/26/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20251205123548

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: NANCY VASQUEZ RESIDENTIAL CARE CENTER	FACILITY NUMBER: 374604751
	VISIT DATE: 03/26/2026

NARRATIVE

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It was alleged that staff mishandled a client's medication. Interviews revealed that
after the incident occurred on 12/4/2025, S1 went to check C1’s medications to ensure that C1 had taken all of their prescribed medications. Interviews revealed that S1 found the bubble pack for C1’s 100 mg prescription of Clozapine in the overflow drawer in the medication room. Interviews revealed that S1 discovered the tablets were still in the bubble pack indicating that C1 had not taken them for approximately two weeks.
Interviews with an outside source revealed the bubble packs were not available to be viewed because C1’s medications were destroyed by facility once C1 left the facility and was admitted to the hospital. Interviews revealed S1 admitted that they neglected to give the medications to C1 for the two week period. Interviews also revealed S2 who is responsible for administering C1’s medication on the days of the week when S1 was off work. Interviews revealed that S2 also admitted that they are unsure if they provided C1 the 100 mg prescription of Clozapine during that two week period. Interviews with outside source Psychiatrist also revealed that C1 missing their prescription for that long of a period could contribute to C1 suffering more delusions and hearing voices. However, C1 was prescribed Haldol that also should have helped their Schizophrenia. Interviews revealed C1 is addicted to Methamphetamine and if they were using Methamphetamine around the time they jumped, the Methamphetamine most likely pushed them over the edge. Based on the investigation, the preponderance of the evidence standard has been met and the allegation of staff mishandled a client's medication is substantiated.

Based on relevant interviews and records review, the preponderance of evidence has been met that the alleged violation occurred and is therefore substantiated. Pursuant to the California Code of Regulations, Title 22, Division 6, deficiencies were cited on the attached 9099-D. Pursuant to the California Code of Regulations, Title 22, Division 6, a deficiency was cited on the attached 9099-D. An immediate civil penalty of $500 was assessed during today’s visit for neglect, lack of care, and supervision resulting in a resident’s hospitalization.

An exit interview was conducted with Nick Fierro, Administrator and a copy of this report and Licensee Rights (LIC9058 03/22) were provided at the conclusion of the visit.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:	DATE: 03/26/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2026

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20251205123548

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: NANCY VASQUEZ RESIDENTIAL CARE CENTER	FACILITY NUMBER: 374604751
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/26/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/24/2026 Section Cited CCR 80078(a)	1 2 3 4 5 6 7	Responsibility for Providing Care and Supervision(a) 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 agrees to schedule an in-service training by an outside source on the topic of care and supervision. Licensee agrees to send sign-in sheet and trainingmaterials to the Department by 04/24/2026.
	8 9 10 11 12 13 14	Based on record review and interviews, the licensee did not ensure that C1 was provided care and supervision, which posed an immediate health, safety, and personal rights risk to 1 (C1) of 42 clients in care.	8 9 10 11 12 13 14
Type A 04/24/2026 Section Cited CCR 80075(b)	1 2 3 4 5 6 7	Health Related Services (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee agrees to schedule an in-service training by an outside source on the topic of medication administration and send proof of scheduling to the Department by 04/24/26. Licensee agrees to send sign-in sheet and training topics to the Department by 3/28/2026.
	8 9 10 11 12 13 14	Based on record review and interviews, the licensee did not ensure that C1 was provided their medications, which posed an immediate health, safety, and personal rights risk to 1 (C1) of 42 clients 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: 03/26/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2026

LIC9099 (FAS) - (06/04)

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