Complaint Investigation Report

The facility is licensed as a Board and Care for adults with mental disabilities, and staff can only encourage regular hygiene practices; they cannot provide personal care beyond the facility’s license scope. Records review of court order dated January 22, 2025, R1 is conserved to a closed (locked) treatment facility.

LPA observed construction is currently being done on the facility for upgrades. R1's room was clean. No one was in the room at the time of the visit. Staff stated Resident R1 was not prescribed any pill-form medications for their diagnosis. Resident received injections from their primary care physician every six months, the last injection was administered in July 2025. Staff reported that resident would often refuse to shower unless provided with a cigarette, or staff would have to contact the resident’s family to encourage compliance. Even with incentives, the resident would frequently refuse to shower altogether.

According to staff, the hospital asked if the resident could be placed at the board and care due to needing the space at the hospital on December 23, 2024; the facility took the resident as a courtesy. However, the Hospital did not notify the conservator that R1 was sent to the facility. R1 was admitted on November 11, 2025, into the hospital due to body lice. R1 was admitted into a Behavioral Health facility and is expected to be discharged to a skilled nursing facility (SNF). All of the resident’s belongings were packed as of November 18, 2025, and the resident will not be returning to the facility.

On November 25, 2025, LPA contacted the County of San Diego Conservator’s Office regarding R1. LPA was informed that the previously assigned conservator no longer works for the department. The new conservator was not available; however, LPA spoke with a representative who stated that R1 was still at the Behavioral Health Facility and there is no discharge date at this time.

Based on interviews and record review, the allegations are unsubstantiated. A finding that is unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violations occurred. An exit interview was conducted with the Administrator. A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided to the Administrator, and her signature on this report confirms receipt of the Licensee Rights.