134604299-8-24-2023-08-AS-DPOL-CV7TWY-20230830150617

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 134604299
Report Date: 08/24/2023
Date Signed: 08/24/2023 12:45:16 PM

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
07/29/2020 and conducted by Evaluator Renita Hall

COMPLAINT CONTROL NUMBER: 08-AS-20200729131655

FACILITY NAME:	PARKSIDE VILLA ASSISTED LIVING		FACILITY NUMBER:	134604299
ADMINISTRATOR:	KAHNIS, KEVIN		FACILITY TYPE:	740
ADDRESS:	1685 CYPRESS DR		TELEPHONE:	(442) 271-4109
CITY:	EL CENTRO	STATE: CA	ZIP CODE:	92243
CAPACITY:	18	CENSUS: 18	DATE:	08/24/2023
		UNANNOUNCED	TIME BEGAN:	12:23 PM
MET WITH:	Sikalalic Garcia, Manager		TIME COMPLETED:	12:35 PM

ALLEGATION(S):

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Staff chemically restrain resident
Resident sustained unexplained injury while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Renita Hall conducted an unannounced visit to deliver findings. LPA was allowed entry by Sikalalic, Manager. LPA identified herself and disclosed the purpose of the visit and shared findings with the Manager.

On July 29, 2020 a complaint was received regarding the alleged incidents that staff chemically restrain resident; resident sustained unexplained injury while in care.

Resident's medication was not changed. LPA unable to verify the medication count at this time. MAR indicate that the medication was given as prescribed. There was no increase in dosages. VA did not order additional medication based on reconciliation documented on VA notes.

Continued on 9099C Amended report.2

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Renita Hall	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023

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

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20200729131655

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: PARKSIDE VILLA ASSISTED LIVING	FACILITY NUMBER: 134604299
	VISIT DATE: 08/24/2023

NARRATIVE

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Resident sustained unexplained injury while in care Licensee was not at facility at the time of the follow-up call on August 18, 2020. Unable to conduct interviews with staff. Currently no indication of a fall or injury at this time. Medical assessment record shows that resident was a fall risk.

Based on the review of documentation, the allegations of: Staff chemically restrain resident and Resident sustained unexplained injury while in care is Unsubstantiated due to a lack of conclusive evidence. A finding that is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

An exit interview was conducted with Sikalalic Garcia, Manager . 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.

Amended Report

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Renita Hall	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023

LIC9099 (FAS) - (06/04)

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