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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 370800558
Report Date: 05/08/2025
Date Signed: 05/08/2025 12:55:54 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
04/30/2025 and conducted by Evaluator Dang Nguyen
COMPLAINT CONTROL NUMBER: 08-AS-20250430143006
FACILITY NAME:ST PAUL'S MANORFACILITY NUMBER:
370800558
ADMINISTRATOR:DAMIEN RAPPFACILITY TYPE:
740
ADDRESS:2635 SECOND AVETELEPHONE:
(619) 239-2097
CITY:SAN DIEGOSTATE: CAZIP CODE:
92103
CAPACITY:200CENSUS: 106DATE:
05/08/2025
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Executive Director Tim Jeffers and Resident Services Coordinator Carol BraunTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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-Licensee pursued unlawful eviction of resident.
-Licensee did not reasonably accommodate resident’s needs/preferences.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced subsequent visit to deliver findings regarding the above prior complaint allegations. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Tim Jeffers and Resident Services Coordinator Carol Braun.

The Complainant alleged that Licensee pursued unlawful eviction of Resident #1 (R1), and that Licensee did not reasonably accommodate R1’s needs/preferences. [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] CCLD’s investigation involved unannounced facility tours, review of relevant records and written correspondence, and interviews of R1, facility managers and staff, and Licensee’s attorney.

[CONTINUED ON LIC 9099-C, 1 of 5]
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025
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 7
Control Number 08-AS-20250430143006
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: ST PAUL'S MANOR
FACILITY NUMBER: 370800558
VISIT DATE: 05/08/2025
NARRATIVE
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[CONTINUED FROM LIC 9099]

Interviews unanimously showed that on 04/10/2025, Licensee served R1 with a letter titled “Re: Notice of Termination of Resident Agreement.” The letter was addressed to R1 and delivered via personal service, E-mail, and US Mail. During this complaint investigation, Licensee told CCLD that the 04/10/2025 letter was not a written notice of eviction. The Department requested and received copies of said letter, both from R1 and from Licensee, which matched.

The letter stated, in part: “Pursuant to Section VII (B)(1)(c), this correspondence services [sic] to notify you that The Manor on Bankers Hill (“The Manor”) will be terminating your Resident Agreement. Please accept this correspondence as your thirty (30) day notice of termination; please begin preparations on your end to vacate your residence.” It also stated, “The basis for this termination is your continued defiance of The Manor’s rules which directly impact the safety and security of the residents at The Manor.” It also stated, “Please ensure that you review your Resident Agreement and comply with your obligations set forth in Section VII (D)(1) with regard to vacating your residence.”

The Department requested and received copies of R1’s signed Resident Agreement contract, both from R1 and from Licensee, which matched. According to this contract: Section VII (B) was titled, “Termination by Us,” and described multiple “eviction provisions,” of which (1)(c) was, “Your failure to comply with the general policies of the Manor.” Section VII (D)(1) was titled, “Vacating Apartment,” and read, in part, “If this Agreement is terminated, you or your estate must vacate the apartment and remove all your property from it,” and “We may also remove your property from the apartment and charge you or your estate a property storage fee if either you or your estate fails to vacate the apartment and remove your personal belongings from it by the effective termination date.”

Based on the above, the Department determined that the 04/10/2025 letter which Licensee served upon R1, was indeed, a written 30-day notice of eviction. Missing in the letter were multiple elements/disclosures required by regulations, contributing to its unlawfulness. (These deficiencies will be addressed in a separate Case Management visit report).

[CONTINUED ON LIC 9099-C, 2 of 5]
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 08-AS-20250430143006
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: ST PAUL'S MANOR
FACILITY NUMBER: 370800558
VISIT DATE: 05/08/2025
NARRATIVE
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[CONTINUED FROM LIC 9099-C, 1 of 5]

Although Licensee’s 04/10/2025 letter did not specify the facility rule/policy R1 allegedly broke, interviews of R1 and facility attorney/managers and E-mails and letters exchanged between the parties aligned to show: The underlying conflict was Licensee’s expectation that R1 manually sign themselves out (using a pen and the three-ring binder atop a podium in the facility’s lobby) upon exiting the facility, and that R1 sign themselves back in upon reentering the facility. R1, however, conveyed to Licensee that they disagreed with signing themselves out/in.

According to California Code of Regulations, Title 22, Section 87224, residents of Residential Care Facilities for the Elderly (RCFEs) may only be evicted from the facility for a few specified reasons, one of which is “(a)(3) Failure of the resident to comply with general policies of the facility.” This regulation states in the next sentence, “Said general policies must be in writing, must be for the purpose of making it possible for residents to live together and must be made part of the admissions agreement.” Section 87506 states, “(g) Admission agreements shall specify the following: (8) General facility policies that are for the purpose of making it possible for residents to live together.” Section 87468.2 states that residents in privately-operated RCFEs must “be fully informed, prior to or at the time of admission, of all rules that govern resident conduct and responsibilities while living at the facility, as evidenced by the resident’s written acknowledgement. All rules established by a licensee shall be reasonable…”

On 01/31/2025, R1 and Licensee jointly signed the Resident Agreement contract, to go into effect on 02/28/2025. Per R1’s Face Sheet, they moved-in to the facility on 02/28/2025. The Resident Agreement contract did not discuss the facility’s expectation that R1 themselves use the sign in/out book, but in Section X (D) stated, “Resident Handbook: You agree to abide by the general policies of the Manor. A copy of the current Resident Handbook is attached as Appendix D and made part of this Agreement. We reserve the right to change the Resident Handbook at any time…” Interviews showed the “Resident Handbook” document was not provided to R1 on 02/28/2025 (the date of contract signing). Instead, the Resident Handbook was first given to R1 during New Resident Orientation, which occurred on 03/06/2025, after R1 had already moved in, as confirmed by the manager who led that meeting.

[CONTINUED ON LIC 9099-C, 3 of 5]
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 08-AS-20250430143006
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: ST PAUL'S MANOR
FACILITY NUMBER: 370800558
VISIT DATE: 05/08/2025
NARRATIVE
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[CONTINUED FROM LIC 9099-C, 2 of 5]

According to R1’s latest LIC602 Physician’s Report (dated 12/27/2024): R1 was ambulatory with no diagnosis of cognitive impairment. R1’s doctor wrote that R1 was not confused, not depressed, able to follow instructions, able to communicate, able to care for all personal needs, able to store and administer their own medications, able to manage their own cash, and able to safely leave the facility unassisted. Interviews of R1, managers, and staff unanimously showed: R1 was their own payee and responsible person, independent in Activities of Daily Living (ADLs), able to walk without cane or walker, able to safely drive a car, was gainfully employed, and time and again safely managed themselves in public and consistently returned to the facility on their own.

According to interviews of facility managers on 05/06/2025, all 106 residents of the facility (including R1) were ambulatory, cognitively-independent, independent in ADLs and medications, and were capable of safely leaving and returning from the facility on their own. Facility managers were unable to convey to the Department how R1’s not singing themselves out/in at the lobby podium precluded any other resident from doing so if they wished, or how it precluded R1 from living peaceably with their peers. All managers and frontline staff interviewed confirmed R1 owned and carried a cell phone, and that they knew how to call R1’s cell phone if they needed to reach R1. Staff confirmed that Licensee also employed other methods to provide passive observation to their independent residents, such as a daily meal attendance checklist and an “I’m Okay” door hanger, which residents reaffix to their front doorknob every day to show they are alive and well. (These latter practices were also described in Licensee’s Absentee Notification Plan.) R1 was agreeable to and cooperating with both the checklist and door hangar methods.

Facility managers stated the main objective of the sign out/in book was for staff/first responders to know how many persons were present inside the building in the event of a fire or similar disaster. CCLD recognizes the practical value that a sign out/in log has. However, the Department is bound to the regulations as they are currently written. California Code of Regulations and Health and Safety Code currently neither require nor prohibit a resident sign out/in log. Per correspondence from the office of the Fire Marshal for the City of San Diego, they too do not require the facility to maintain a resident sign out/in log. They, along with CCLD, do require Licensee to maintain an up-to-date list/register of residents in care with notations about those who are incapable of self-evacuation (i.e. those who are classified as “non-ambulatory” or “bedridden”). [CONTINUED ON LIC 9099-C, 4 of 5]
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 7
Control Number 08-AS-20250430143006
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: ST PAUL'S MANOR
FACILITY NUMBER: 370800558
VISIT DATE: 05/08/2025
NARRATIVE
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[CONTINUED FROM LIC 9099-C, 3 of 5] The facility’s “Resident Handbook” stated, “Residents are requested to sign in and out whenever entering or leaving our community.” A subsequent 04/10/2025 written memorandum from Licensee to all residents on this same topic similarly used the word “asked.” Such permissive language is congruent with current regulations.

On 04/11/2025, the day after R1 received their 30-day notice letter, R1 wrote to Licensee, explaining that they are sometimes in a hurry to leave the facility and cannot afford to wait behind other residents who are also singing out at the same book. (R1 is gainfully employed, frequently commuting to their nearby office or meeting clients by appointment). R1 offered going forward to sign out verbally or via phone call to the receptionist, in lieu of manually writing in the book. (The facility staffs a receptionist at their front desk 24/7). On 04/13/2025, Licensee wrote back denying R1’s proposed compromise. R1 then attended an in-person meeting with facility managers on 04/27/2025, reiterating their willingness to sign out/in verbally but not manually; R1's request was again denied. During CCLD’s first site visit for this complaint on 05/06/2025, LPA asked facility management why R1’s request for accommodation was untenable if it represented a step forward in the direction of Licensee’s stated goal of “fire safety.” Managers replied that their lobby receptionists were too busy with daily job tasks to write down that R1 left the building, and that they did not intend to rescind their 04/10/2025 letter to R1. Per manager interviews, as of that date, no residents beside R1 were known to either oppose or to consistently forget to manually sign themselves out. In other words, R1’s request for accommodation regarding the sign out/in book was the only such one.

LPA subsequently interviewed multiple facility receptionists, each of whom confirmed they daily write their observations as they occur in the “St. Paul’s Manor Daily Log,” an electronic document which they keep updated via their front desk computer. LPA subsequently studied a sampling of this log spanning six (6) consecutive shifts, finding the receptionist team wrote ninety-seven (97) bullet-point style entries during this span, of which twenty-six (26) were directly concerning residents coming or going from the facility. They also wrote about numerous individuals’ package deliveries and pickups, lost and found items, and even the trash utility company coming to empty the facility’s trash.


[CONTINUED ON LIC 9099-C, 5 of 5]
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 08-AS-20250430143006
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: ST PAUL'S MANOR
FACILITY NUMBER: 370800558
VISIT DATE: 05/08/2025
NARRATIVE
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[CONTINUED FROM LIC 9099-C, 4 of 5]

Based on records and interviews, a preponderance of evidence exists to show that Licensee pursued unlawful eviction of R1, and that Licensee did not reasonably accommodate R1’s needs/preferences. Both allegations were therefore Substantiated, and two (2) deficiencies were cited for them per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D page). Plans of Correction were jointly developed with the Licensee.

An exit interview was conducted with Jeffers and Braun, to whom a copy of this report, the LIC 9099-D page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 08-AS-20250430143006
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ST PAUL'S MANOR
FACILITY NUMBER: 370800558
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/09/2025
Section Cited
CCR
87224(a)(3)
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87224 Eviction Procedures: “(a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5)… (3) Failure of the resident to comply with general policies of the facility. Said general policies must be in writing, must be for the purpose of making it possible for residents to live together and must be made part of the admission agreement.” This requirement was not met, as evidenced by:
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Licensee agreed to immediately rescind the eviction notice letter which was served to R1 on 04/10/2025, and to notify R1 of such in writing. Licensee agreed to E-mail a copy of the rescinding notice to LPA, by the POC due date.
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Based on records review and interviews, Licensee served an eviction notice to 1 of 106 residents (R1) for failure to comply with a general policy of the facility, but said policy was not for the purpose of making it possible for residents to live together and was not fully disclosed at the time the admissions agreement was signed. This posed a potential personal rights risk to persons in care.
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Type B
05/09/2025
Section Cited
CCR
87468.2(a)(14)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: “(a) …residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (14) To reasonable accommodation of their individual needs and preferences in all aspects of life in the facility…” This requirement was not met, as evidenced by:
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Licensee agreed to immediately allow R1 the options of signing out/in manually, OR verbally / by phone call with the receptionist, when they are leaving/returning to the facility building. Licensee agreed to provide R1 written notice of such, and to E-mail a copy of said correspondence to LPA, by the POC due date.
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Based on records review and interviews, Licensee did not reasonably accommodate the individual need/preference of 1 of 106 residents (R1) regarding their life at the facility, when the specific accommodation that R1 requested was reasonable with regard their safety and those of peers. This posed a potential personal rights risk to persons in care.
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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: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 7