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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370800558
Report Date: 01/11/2024
Date Signed: 01/11/2024 03:43:59 PM


Document Has Been Signed on 01/11/2024 03:43 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 MANORFACILITY NUMBER:
370800558
ADMINISTRATOR:DAMIEN RAPPFACILITY TYPE:
740
ADDRESS:2635 SECOND AVETELEPHONE:
(619) 239-2097
CITY:SAN DIEGOSTATE: CAZIP CODE:
92103
CAPACITY:200CENSUS: 64DATE:
01/11/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:06 PM
MET WITH:Resident Services Coordinator Carol Braun and Executive Director Tim JeffersTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced, subsequent Case Management visit to cite deficiencies resulting from an incident self-reported by the licensee. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Resident Services Coordinator Carol Braun. LPA also met with Executive Director Tim Jeffers.

On 09/05/2023, the CCLD San Diego Regional Office received an LIC624 Incident Report from the licensee. Per the LIC624: On 08/31/2023 around 4:00 PM, Resident #1 (R1) fell at the facility, requiring them to be sent to a hospital emergency room for medical care. [See LIC 811 Confidential Names List for a description of person identifiers used].

CCLD’s investigation involved a brief facility tour on 09/18/2023, followed by welfare check on R1 via a collateral visit. CCLD also interviewed relevant residents, staff, and outside sources, and reviewed pertinent care records and correspondence.

According to R1’s LIC602 Physician’s Report and corroborated by the appraisals/assessments which Licensee performed on R1: for most of R1’s residency at the facility (which began in 2017), R1 was historically independent with Activities of Daily Living (ADLs), to include walking and transferring, and required no assistive device such as a cane, walker, or wheelchair.

Records and interviews of residents and staff, aligned to show: On 08/29/2023, R1’s spouse and roommate, Resident #2 (R2) approached facility management to tell them that R1 was falling frequently inside their bedroom, and that this new trend had occurred over the last “couple of weeks.” R2 admitted that they initially did not report R1’s falls to staff, but now recognized staff help was needed to maintain R1’s safety. Then on 08/31/2023, R1 fell at the facility, sustaining a nosebleed, skin lacerations on forehead and knee, and bruising to face, buttock, and leg. [CONTINUED ON LIC 809-C]
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 01/11/2024
NARRATIVE
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[CONTINUED FROM LIC 809] Medical records showed R1 was diagnosed with a fracture of “C5 endplate” (i.e., a bone in their neck), for which R1 had to wear a collar device. R1 told CCLD they also experienced changes in their visual perception / processing, which lasted for a few weeks after the fall.

Records, interviews, and E-mails further showed: From the time Licensee received constructive knowledge of R1’s new fall-risk on 08/29/2023, until the time R1 fell and was hospitalized on 08/31/2023, Licensee verbally told R2 that R1 needed to relocate to another care facility since R1’s now required caregiving assistance. However, Licensee’s staff did not meet with R1 in person to perform a written reappraisal of their care needs, nor notify R1’s physician of what R2 reported to them about R1. Licensee also did not assign any caregiver to R1 to help mitigate fall risk, either from its own staff pool or from a contracted outside source (such as a home care agency).

On 09/01/2023, hospital staff determined R1 was ready to be discharged back to the facility, but facility management told hospital staff that R1 could not return to the facility to due needing a higher level of care. R1 instead went to a skilled nursing facility (SNF). On 09/02/2023, facility management referred R2 to a third-party placement/referral agent, who subsequently helped R1 move from the SNF to another permanent residence. Licensee did not issue R1 a 30-day written notice to move-out from the facility, as was required. E-mail and interviews showed R1’s move-out occurred under duress: R2 appealed to the SNF to extend R1’s stay to allow the more time to research and find another residence for them, but that appeal was denied. Unable to return to St. Paul’s Manor, R1 was discharged to their new residence on 09/12/2023.

Based on records and interviews, a preponderance of evidence exists to show: a) Upon receiving constructive knowledge of a change in condition, Licensee did not observe/reappraise R1, report changes to R1’s physician, and provide appropriate assistance for R1’s unmet need, as were required; and, b) Licensee evicted R1 from the facility without giving them the required 30-day written notice.

Two (2) deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D pages). One of the violations was material to R1 sustaining serious bodily injury; an immediate civil penalty of $500 was also assessed (refer to the LIC421-IM). Plans of Correction was jointly developed with the licensee.

An exit interview was conducted with Braun and Jeffers, to whom a copy of this report, the LIC 809-D, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/11/2024 03:43 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 01/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/12/2024
Section Cited
CCR
87466

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87466 Observation of the Resident: “The licensee shall ensure that residents are regularly observed for changes in physical…functioning and that appropriate assistance is provided when such observation reveals unmet needs…the licensee shall ensure that such changes are documented and brought to the attention of the resident’s physician…”
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Per manager interviews, Licensee does not self-employ caregivers, due to residents of the facility being independent in ADLs at the time of their admission. Licensee thus agreed to choose and formally retain (i.e., sign contracts with) three licensed home care organizations (HCOs) that it can partner with to hire contracted caregivers, on an as-needed basis. Licensee also agreed to utilize a third-party source to facilitate training for its managers. The training will cover: 1. A debrief of the incident, b. Regulations 87466 Observation of the Resident and 87463 Reappraisals, and c. where the contact info for its three preferred HCOs will be posted. By the POC due date, Licensee agreed to E-mail to LPA: a) the names and phone numbers of its three preferred HCOs, and b) the planned date for the manager training. By 02/10/2024, Licensee agreed to E-mail LPA a copy of the training sign-in sheet.
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This requirement was not met, as evidenced by: Based on records and interviews, for 1 of 64 residents (R1), Licensee did not ensure that changes in physical functioning were observed, documented, and brought to the attention of their physician, and that appropriate assistance was provided for an unmet need. This posed an immediate health and safety risk to persons in care.
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Type B
02/10/2024
Section Cited
CCR87224(a)

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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). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5).”
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Licensee agreed to utilize a third-party source to facilitate training for its managers. The training will cover Regulation 87224 Eviction Procedures. By the POC due date, Licensee agreed to E-mail to LPA a copy of the training sign-in sheet.
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This requirement was not met, as evidenced by: Based on records and interviews, Licensee evicted 1 of 64 residents (R1) without providing thirty (30) days written notice to the resident.” 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.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2024
LIC809 (FAS) - (06/04)
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