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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604751
Report Date: 06/26/2026
Date Signed: 06/26/2026 04:12:36 PM

Document Has Been Signed on 06/26/2026 04:12 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 CENTERFACILITY NUMBER:
374604751
ADMINISTRATOR/
DIRECTOR:		CURTIS, PHILIP C.FACILITY TYPE:
735
ADDRESS:8627 TROY STREETTELEPHONE:
(619) 754-5250
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY: 42CENSUS: 41DATE:
06/26/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Nick Fierro, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:20 PM
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Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Nick Fierro, Administrator

Today's visit was in response to Licensee’s self-reported AWOL and a self report for a medication error and a self harm incident for Clients 1,2, and 3 (C1, C2, C3), received at the CCLD San Diego Regional Office on 06/22/2026, 06/23/2026 and 06/24/2026.

[See LIC 811 Confidential Names List for a description of C1-C3]. Per the reports, there was a report was for a self harm incident on 06/15/2026, a report for a medication error on 06/22/2026 and a report for a client that went AWOL on 06/23/2026.

The AWOL took place and a missing persons report was filed on 06/23/2026. Interviews revealed that C1 returned on 06/25/2026. The facility followed their absentee notification plan.

The medication error occurred and the staff immediately notified the administrator and they notified the on call pharmacist and they were advised to withhold the bedtime medication for one day for C2. They monitored the client for any side effects for the rest of the night. There were no signs of distress or physical symptoms resulted.

The last report occurred on 06/15/2026 when a client tried to commit self harm. C3 told staff that they had consumed alcohol. The on-duty Case Aide, intervened during the call to 911 that the client made to assist the dispatcher due to communication difficulties and provided the clients mental health history. EMS did not respond to the initial phone call, and according to staff the client did not appear to be in any distress and went to bed.

NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Tiffany Holmes
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/26/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/26/2026
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 The resident was kept under intermittent observation until the shift hand-off occurred. At approximately 7:45 AM, the case aide arrived on-site and performed a routine safety checks and observed the client in their room, sleeping with no signs of distress. Around 10:30 AM when the client was found, they were foaming at the mouth and unresponsive by Case Aide. They immediately made an emergency call to 911. EMS arrived on-site shortly after the call was made and stabilized the client, then transported the client via ambulance to the Hospital.

During today’s visit, LPA briefly toured the facility, collected and reviewed care records on C1- C3, and interviewed staff. LPA performed a cursory welfare check on the remaining clients in care, finding no immediate safety concerns.

During a review of records, LPA observed and manager interview confirmed: C1- C3 had current up to date physician reports and absentee notification plans.

A deficiency was cited during todays visit regarding the medication error.

An exit interview was conducted with Nick Fierro, Administrator to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Tiffany Holmes
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2026
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 06/26/2026 04:12 PM - It Cannot Be Edited


Created By: Tiffany Holmes On 06/26/2026 at 02:46 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 06/26/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/10/2026
Section Cited
CCR
80075(b)

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80075 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:
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Licensee will continue to track staff and medication management. These actions resolved the immediate risk. Licensee agreed to have a medication training for all staff on the 7 rights and submit a sign in sheet from all staff and a copy of training materials to CCL by POC due date of 07/10/2026.
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Based on observation, records, and interviews, Licensee did not ensure that 1 of 41 clients (C1) was assisted as needed with self-administration of the correct prescription medications, which posed an immediate health risk to persons 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.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Tiffany Holmes
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/26/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/26/2026


LIC809 (FAS) - (06/04)
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