374604920-4-6-2026-08-AS-RCLK-DTN24L-20260430170406

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604920
Report Date: 04/06/2026
Date Signed: 04/06/2026 01:34:01 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
12/19/2025 and conducted by Evaluator Jose DeLaCruz

COMPLAINT CONTROL NUMBER: 08-AS-20251219142239

FACILITY NAME:	NEW BEGINNING LIVING INC		FACILITY NUMBER:	374604920
ADMINISTRATOR:	VAZQUEZ, OCTAVIO		FACILITY TYPE:	740
ADDRESS:	2275 INGRID AVE		TELEPHONE:	(619) 481-4862
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92154
CAPACITY:	6	CENSUS: 5	DATE:	04/06/2026
		UNANNOUNCED	TIME BEGAN:	12:20 PM
MET WITH:	Administrator Octavio Vazquez		TIME COMPLETED:	01:50 PM

ALLEGATION(S):

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Neglect resulting in serious bodily injuries
Staff did not seek timely medical attention for resident

INVESTIGATION FINDINGS:

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On 04/06/2026 Licensing Program Analyst (LPA) Jose De La Cruz arrived to the facility to conclude a complaint investigation initiated on 12/22/2025. LPA was greeted by Administrator Octavio Vazquez.

On 12/19/2025, it was alleged that Resident 1 (R1) sustained serious bodily injuries, including pressure injuries and foot infection, due to facility neglect and that the facility failed to obtain emergency medical care for a worsening foot infection.

On 12/22/2025, the Department conducted a welfare check and collected records related to the incident. R1 was not present, having been admitted to the hospital. Subsequent interviews and record reviews were completed with internal and external sources.

[CONTINUED ON LIC9099-C]

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Jose DeLaCruz
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2026

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 4

Control Number 08-AS-20251219142239

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: NEW BEGINNING LIVING INC	FACILITY NUMBER: 374604920
	VISIT DATE: 04/06/2026

NARRATIVE

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[CONTINUED FROM LIC9099]

Records and interviews revealed that R1 was admitted to the facility on 11/7/2025. Their 10/7/2025 medical assessment and 11/8/2025 appraisal documented diabetes, Alzheimer’s disease, a history of pressure ulcers, which were healed at the time of the assessment. R1 was bedridden and required full assistance with activities of daily living (ADLs). At admission, the administrator (ADM) and one staff (S1) assessed R1. ADM reported that R1’s right great toenail appeared swollen, red, and possibly infected upon admission. S1 stated the toenails were long and the toe worsened over time.

Charting shows that 11/11/2025, ADM documented redness on R1’s feet and toenails and notified the Licensee, who planned staff training. No further related documentation was indicated until 12/5/2025, when ADM recorded that R1’s responsible person (OS1) reported a possible foot infection. On 12/10/2025, R1 was hospitalized during a routine doctor appointment due to the progressed infection, which was not addressed by the facility until it was found by outside source (OS1).

During interviews, ADM and S1 acknowledged observing the toe worsen and that R1 complained of pain. S1 reported this to R1’s responsible person, who arranged a podiatry appointment with a two month wait. Neither ADM nor SI notified R1’s physician. When asked by the Department, ADM stated no medical care was obtained because R1’s responsible person was already aware and no other skin issues were noted.

ADM also confirmed that R1 began developing wounds after attending a day program in late November. Charting corroborated this and documented that on 12/5/2025, R1 returned from day program with a re-opened wound on their upper left back. Three days later, it was noted that R1’s medical provider was contacted to request a wound assessment, guidance for treatment, and any wound care supplies. S1 said that on 12/9/2025, R1 returned from the program with bandages, cream, and instructions for a pressure wound on the shoulder and for the toe. ADM acknowledged that the wound had progressed and reported that they notified R1’s physician, and not their responsible party when it progressed.

[CONTINUED ON LIC9099-C]

SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Jose DeLaCruz
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2026

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20251219142239

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: NEW BEGINNING LIVING INC	FACILITY NUMBER: 374604920
	VISIT DATE: 04/06/2026

NARRATIVE

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[CONTINUED FROM LIC9099-C]

Staff two (S2), responsible for bathing and skin checks, confirmed receiving instructions to apply cream to the pressure injury when repositioning R1 every two hours but denied noticing concerns about the toe.
Interviews were conducted with OS1 and R1’s physician (PCP), who became R1’s provider on 12/1/2025. During an intake assessment on 12/8/2025, PCP noticed R1’s infected toe and a stage 2 pressure injury on the upper left shoulder. A follow up on 12/10/2025 showed progression, including blood around the toenail bed, posing significant risk due to R1’s diabetes. Emergency treatment was arranged, and R1 was hospitalized for five days before transferring to a skilled nursing facility for extended treatment. PCP stated they were never notified by the facility of R1’s progressed toe infection.

Hospital records reviewed from 12/10/2025–12/15/2025 confirm diagnoses with photos of diabetic ulcers on both great toes, a diabetic foot infection, and pressure injuries to the sacrum and upper left back. R1 required hospitalization for five days and subsequent treatment at a skilled nursing facility following hospital discharge on 12/15/2025.

A preponderance of evidence supports that facility staff failed to observe R1’s changes in condition and report as required to R1’s responsible person and physician. The evidence further supports that the facility did not arrange emergency medical care for a serious toe infection which required hospitalization.

Both allegations are substantiated and cited on LIC 9099(d). Pursuant to Health and Safety Code §1568.0822 an immediate civil penalty was assessed (see LIC 421 IM). Additional civil penalties remain under review with the Department’s legal division and may be assessed at a later date.

An exit interview was conducted, and the report and appeal rights were provided to Administrator Octavio Vazquez, whose signature acknowledges receipt.

SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Jose DeLaCruz
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2026

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20251219142239

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: NEW BEGINNING LIVING INC	FACILITY NUMBER: 374604920
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/06/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 04/07/2026 Section Cited CCR 87465(a)(1)	1 2 3 4 5 6 7	A plan for… medical… care shall be developed by each facility…. by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental... This requirement was not met as evidenced by.	1 2 3 4 5 6 7	Licensee will arrange, or assist in arranging, for medical and dental care for the needs of residents.
	8 9 10 11 12 13 14	Based on interview and record review, the licensee did not arrange medical care for one residents (R1) severe toe infection resulting in hospitalization. This posed an immediate health safety and personal rights risk to 1 of 5 residents in care.	8 9 10 11 12 13 14
Request Denied Type A 04/07/2026 Section Cited CCR 87466	1 2 3 4 5 6 7	The licensee shall ensure that residents … the licensee shall ensure that such changes are ... brought to the attention of the resident's physician and ... responsible person, if any. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee shall reach out to responsible partied and residents physician when updates to the resident's health are observed.
	8 9 10 11 12 13 14	Based on record review and interview, the licensee did not report two (2) changes in condition for one resident (R1) to their responsible person and physician. This posed a immediate risk to 1 of 5 residents 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: Robyn Clark
LICENSING EVALUATOR NAME: Jose DeLaCruz
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2026

LIC9099 (FAS) - (06/04)

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