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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 370800930
Report Date: 10/13/2021
Date Signed: 10/13/2021 03:59:39 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
09/01/2021 and conducted by Evaluator Alexandre Vo
COMPLAINT CONTROL NUMBER: 08-AS-20210901084241
FACILITY NAME:ST MADELEINE SOPHIES CENTERFACILITY NUMBER:
370800930
ADMINISTRATOR:DEBRA EMERSONFACILITY TYPE:
775
ADDRESS:2119 E. MADISON AVENUETELEPHONE:
(619) 442-5129
CITY:EL CAJONSTATE: CAZIP CODE:
92019
CAPACITY:400CENSUS: 125DATE:
10/13/2021
UNANNOUNCEDTIME BEGAN:
02:28 PM
MET WITH:Administrators, Thomas Carr and Debra EmersonTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility improperly discharged client
Client was not treated with dignity
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Alexandre Vo, conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegations. LPA was allowed entry into the facility after identifying himself and stating the purpose of the visit. LPA met with Administrators, Thomas Carr and Debra Emerson.

The Department’s investigation included interviews and documents review. On August 26, 2021 facility staff was notified that a Day Program participant’s family member tested positive for COVID-19. As part of their mitigation procedures to prevent the spread of COVID-19 amongst other participants and their staff, the facility took measures they deemed were necessary for continued operation during pandemic circumstances. Facility staff attempted to determine whether the client had close contact with the affected family member.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Alexandre Vo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021
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 3
Control Number 08-AS-20210901084241
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 MADELEINE SOPHIES CENTER
FACILITY NUMBER: 370800930
VISIT DATE: 10/13/2021
NARRATIVE
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It was alleged that a client was improperly isolated and sent home from day program, violating their personal rights. Based on interviews, Client #1 (C1, refer to list of confidential names) was isolated on August 26, 2021 while facility staff attempted to determine the timeline of the COVID-19 infection or close contact. Based on interviews with facility staff, the client’s close contact with their family member was irresolute. There were inconsistent statements as to the close contact, in which the family member denied that the client was within six feet of the affected individual therefore, a diagnostic test was not conducted. Furthermore, the client was not presenting with symptoms of COVID-19, e.g. fever, coughing, sneezing, etc. COVID-19 response testing for Adult Day Program participants are not mandatory. The client was subsequently sent home from the day program. The client’s immunization record was also reviewed regarding the requirement for testing of fully or not fully vaccinated persons. Based on C1’s vaccination status, lack of a positive COVID-19 diagnostic, no COVID-19 symptoms, and close contact could not be established, it was determined that this allegation is substantiated because the preponderance of the evidence standard has been met.

It was alleged that C1 was improperly discharged from the Day Program. Review of e-mail exchanges between the family member and facility staff on August 30, 2021 confirmed C1 was discharged from the day program and was given an end date of September 24, 2021. Based on interviews, the facility can continue to meet C1’s needs, as well as, there were no changes in C1’s medical condition that would have rendered C1 unable to participate in the program. The facility did not document a reassessment of the client’s needs. Therefore, this allegation is substantiated because the preponderance of the evidence standard has been met and the facility did not properly discharge the client based on being able to meet their needs.

Citations are being issued in accordance with California Code of Regulations, Title 22, and listed on the 9099D. Plans of Corrections were developed with the Administrator. An exit interview was conducted. A copy of this report and Appeal Rights (9058 01/16) were provided to the administrator, whose signature on this form confirms receipt of these documents.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Alexandre Vo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20210901084241
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 MADELEINE SOPHIES CENTER
FACILITY NUMBER: 370800930
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/15/2021
Section Cited
CCR
82072(a)(1)
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82072 Personal Rights (a) Each client shall have personal rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. This requirement was not met as evidenced by:
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Licensee agreed to conduct in-service management training regarding COViD-19 symptoms in accordance with current guidance. Training roster and materials due to LPA by POC date.
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Based on interviews and records review, the licensee did not treat the client with dignity in their personal relationships. This posed a potential personal rights violation to one of the clients in care.
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Type B
11/15/2021
Section Cited
CCR
92068.5(a)
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82068.5 Procedures for Discharge (a) A minimum of two weeks' notice shall be given to a client and his/her family and care providers if the Adult Day Program determines that the day program can no longer meet the needs of the client, and he/she must be discharged from the day program.
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Licensee agreed to update their Admission Agreement/Plan of Operation to LPA by POC date.
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This requirement was not met as evidenced by: Based on interviews and records review, the licensee did not discharge the client based on being able to meet their needs. This posed a potential personal rights violation to one of the clients 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: Simon Jacob
LICENSING EVALUATOR NAME: Alexandre Vo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3