370808051-4-22-2025-08-AS-SJAB-DG8SVF-20250430141240

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 370808051
Report Date: 04/22/2025
Date Signed: 04/22/2025 07:54:30 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
03/20/2025 and conducted by Evaluator Marisela Garcia-Centeno

COMPLAINT CONTROL NUMBER: 08-AS-20250320132632

FACILITY NAME:	MARSELL'S ADULT RESIDENTIAL FACILITY #2		FACILITY NUMBER:	370808051
ADMINISTRATOR:	MARTHA SELL		FACILITY TYPE:	735
ADDRESS:	1460 E. LEXINGTON		TELEPHONE:	(619) 328-0030
CITY:	EL CAJON	STATE: CA	ZIP CODE:	92021
CAPACITY:	4	CENSUS: 4	DATE:	04/22/2025
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Staff, Kimberly Wallman		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff opened a client's mail

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced visit to deliver investigative findings. LPA was greeted by Staff, Kimberly Wallman, to whom she identified herself and explained the purpose of the visit. LPA delivered findings over the telephone with Administrator, Dawnne Melton.

The Department investigated the above-listed complaint allegation. The investigation included a facility tour, multiple interviews with staff and outside sources, and a review of relevant client and facility records and other supporting documentation.

On March 20, 2025, Community Care Licensing (CCL) received a complaint alleging that staff opened a client’s (C1) mail. [An LIC 811 Confidential Names List was provided to staff to identify C1.] It was specifically alleged that on March 13, 2025, a staff member opened C1’s mail without their permission.

(continue at LIC9099Cf)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno	TELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025

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 6

Control Number 08-AS-20250320132632

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: MARSELL'S ADULT RESIDENTIAL FACILITY #2	FACILITY NUMBER: 370808051
	VISIT DATE: 04/22/2025

NARRATIVE

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(continue from LIC9099)

During staff interviews conducted on March 26, 2025, staff admitted to opening C1’s mail. Staff explained that they were actively assisting C1 and C1’s placement agency in reestablishing C1’s public assistance benefits. They were expecting important documents from a government agency to arrive at the facility, which were needed to complete the benefits reapplication process.

Staff consistently stated that they were monitoring C1’s mail closely to ensure timely processing of the documents, as C1’s benefits had been canceled over six months prior due to fraudulent activity. Staff indicated they only opened mail related to this specific situation and that all other mail was delivered to C1 unopened.

Interviews with staff and clients confirmed that this was an isolated incident and not standard protocol. Staff acknowledged the importance of respecting clients’ rights and agreed that going forward, all personal and official mail would be delivered to C1 unopened.

The Department has investigated the above-mentioned allegation and found sufficient evidence to corroborate it. Therefore, this allegation is deemed substantiated. A substantiated finding means the allegation is valid because the preponderance of the evidence standard has been met.

A deficiency was cited in accordance with Title 22, Division 6, Chapter 8 of the California Code of Regulations, and is documented on LIC 9099-D. A plan of correction was developed in collaboration with Administrator Dawnne Melton.

An exit interview was conducted with Staff, Kimberly Wallman, to whom a copy of this report, the LIC 811 Confidential Names List, and the Licensee Appeal Rights (LIC 9058 03/22) were provided at the conclusion of the visit.

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno	TELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 08-AS-20250320132632

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: MARSELL'S ADULT RESIDENTIAL FACILITY #2	FACILITY NUMBER: 370808051
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/22/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/22/2025 Section Cited CCR 85072(b)(10)	1 2 3 4 5 6 7	85072(b)(10) Personal Rights The licensee shall insure that each client is accorded the following personal rights. To mail and receive unopened correspondence. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	LIcensee agreed to conduct personal rights training wilth all staff. Licensee agreed to submit training documentation to CCL by POC date of 5-22-2025.
	8 9 10 11 12 13 14	Based on observations, interviews, and records review, the Licensee did not ensure client (C1’s) mail was received unopened. This posed a personal rights risk to one (1) of four (4) clients in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno	TELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 6

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
03/20/2025 and conducted by Evaluator Marisela Garcia-Centeno

COMPLAINT CONTROL NUMBER: 08-AS-20250320132632

FACILITY NAME:	MARSELL'S ADULT RESIDENTIAL FACILITY #2		FACILITY NUMBER:	370808051
ADMINISTRATOR:	MARTHA SELL		FACILITY TYPE:	735
ADDRESS:	1460 E. LEXINGTON		TELEPHONE:	(619) 328-0030
CITY:	EL CAJON	STATE: CA	ZIP CODE:	92021
CAPACITY:	4	CENSUS: 4	DATE:	04/22/2025
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	House Manager, Amanda Allcock		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff did not meet client's food service needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced visit to deliver the findings of the above complaint allegation. LPA was greeted by Staff, Kimberly Wallman, to whom she identified herself and explained the purpose of the visit. LPA delivered findings over the telephone with Administrator, Dawnne Melton.

On March 20, 2025, Community Care Licensing (CCL) received a complaint alleging that staff did not meet Client 1’s (C1) food service needs. [An LIC 811 Confidential Names List was provided to staff to identify C1.] Specifically, it was alleged that food availability was limited and that there was not enough food for all clients.

During an interview conducted on March 26, 2025, C1 stated that they prepared their own breakfast and lunch without staff assistance. During the visit, C1 walked around the kitchen, pointed to the food stored in the pantries, and indicated there was enough food to prepare breakfast, lunch, and dinner.

(continue at LIC9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno	TELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025

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

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 08-AS-20250320132632

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: MARSELL'S ADULT RESIDENTIAL FACILITY #2	FACILITY NUMBER: 370808051
	VISIT DATE: 04/22/2025

NARRATIVE

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Continue from LIC 9099

C1 shared that staff did not purchase the snacks they preferred but confirmed there was plenty of food available for meals. C1 expressed a desire for more preferred snacks to be purchased.

Multiple interviews with staff and outside sources consistently indicated that C1 had a medical condition requiring dietary management, specifically limiting foods high in sugar. A review of C1’s medical records confirmed the presence of a medical condition that recommended a low-sugar diet. Additionally, a review of C1’s Individual Program Plan (IPP) showed that one of C1’s primary goals was to make healthier food choices to help manage the condition. Staff interviews consistently revealed that while staff encouraged C1 to make healthier snack choices, C1 ultimately retained the right to choose what they wanted to eat.

During the annual inspection on March 17, 2025, it was observed that the facility had at least two days of perishable food and seven days of non-perishable food that were accessible and safely stored. During another visit on March 26, 2025, three food pantries and the refrigerator/freezer were observed to be fully stocked with a variety of snacks, beverages, and fresh fruits. The refrigerator/freezer contained at least two days’ worth of perishable food (milk, juice, eggs, meats, vegetables, cheese, etc.), and the pantries met the requirement of at least seven days’ worth of non-perishable food, per Title 22 regulations.

Multiple interviews with clients and staff indicated that the facility had sufficient food to meet clients’ needs. Clients consistently reported that they prepared their own breakfasts and packed lunches without issues regarding food supply. Staff were responsible for cooking and serving dinner to all clients daily. A review of grocery delivery records for March 2025 confirmed that food purchases occurred weekly or more frequently, as needed.

A detailed review of the facility’s menus for January, February, and March 2025 indicated that meal selections complied with the USDA basic food group plan. The menus reflected a variety of meals that met food service requirements.

(continue at LIC9099C)

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno	TELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 08-AS-20250320132632

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: MARSELL'S ADULT RESIDENTIAL FACILITY #2	FACILITY NUMBER: 370808051
	VISIT DATE: 04/22/2025

NARRATIVE

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(continue from LIC9099C)

Based on LPA’s interviews, observations, and records reviews, there is not a preponderance of evidence to prove the alleged violation occurred. Therefore, the allegation is deemed unsubstantiated.

No violations were issued during today’s visit.

An exit interview was conducted with Staff, Kimberly Wallman. A copy of this report, the LIC 811 Confidential Names List, and the Licensee/Appeal Rights (LIC 9058 3/22) were provided at the conclusion of the visit.

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno	TELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025

LIC9099 (FAS) - (06/04)

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