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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604996
Report Date: 10/05/2026
Date Signed: 10/05/2026 10:48:11 AM

Unsubstantiated


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
09/25/2026 and conducted by Evaluator David Roman
COMPLAINT CONTROL NUMBER: 08-AS-20260925094805
FACILITY NAME:ISLAND GROVE GUEST HOME IIFACILITY NUMBER:
374604996
ADMINISTRATOR:SHAND, HILLELFACILITY TYPE:
740
ADDRESS:12624 WILLOW ROADTELEPHONE:
(909) 800-4676
CITY:LAKESIDESTATE: CAZIP CODE:
92040
CAPACITY:14CENSUS: 13DATE:
10/05/2026
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Lucero Ochoa, Facility ManagerTIME COMPLETED:
11:02 AM
ALLEGATION(S):
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Staff does not ensure wound care is being provided as ordered.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) David Roman conducted an unannounced visit to conduct a complaint investigation, record review, interview staff and outside sources. LPA D. Roman also delivered findings in the above complaint allegation. LPA identified himself and discussed the purpose of the visit with Facility Manager, Lucero Ochoa.

On September 25, 2026, Community Care Licensing Division (CCLD) received a complaint alleging facility staff does not ensure wound care is being provided as ordered. During the investigation, LPA D. Roman collected pertinent facility records, conducted interviews with the resident's family, and facility staff. Interviews revealed contradicting information regarding the complaint allegation, as the resident's family had no complaints about the facility's competence pertinent to wound care services and staff interviews revealed that wound care services are being provided by PACE Monday through Friday, and facility staff care for the wound on weekends.

(Cont. on LIC9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: David Roman
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2026
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 2
Control Number 08-AS-20260925094805
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: ISLAND GROVE GUEST HOME II
FACILITY NUMBER: 374604996
VISIT DATE: 10/05/2026
NARRATIVE
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Based on evidence obtained, the preponderance of evidence standard was not met, therefore, the allegation was unsubstantiated.

An exit interview was conducted with Facility Manager, Lucero Ochoa, to whom a copy of this report and Licensee/Appeals Rights were provided.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: David Roman
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2