370800930-6-2-2023-08-AS-DNGN-CPGSZ7-20230228131840

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 370800930
Report Date: 02/28/2023
Date Signed: 06/02/2023 01:12:14 PM

Document Has Been Signed on 06/02/2023 01:12 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 MADELEINE SOPHIES CENTER		FACILITY NUMBER:	370800930
ADMINISTRATOR:	DEBRA EMERSON		FACILITY TYPE:	775
ADDRESS:	2119 E. MADISON AVENUE		TELEPHONE:	(619) 442-5129
CITY:	EL CAJON	STATE: CA	ZIP CODE:	92019
CAPACITY: 400		CENSUS: 370	DATE:	02/28/2023
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Chief Executive Officer Debra Emerson and Director of Programs Thomas Carr		TIME COMPLETED:	01:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced, subsequent Case Management visit to cite a deficiency resulting from an investigation conducted on an incident self-reported by the licensee. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Chief Executive Officer Debra Emerson. LPA also met with Director of Programs Thomas Carr, who arrived later during the visit. On 02-02-2023, the CCLD San Diego Regional Office received an LIC624 Unusual Incident Report from licensee. Per the LIC624: during a 01-25-2023 outdoor hiking activity chaperoned by Staff #1 (S1), Client #1 (C1) became separated from the group and was missing for “at least 30 minutes.” [See LIC811 Confidential Names List for a description of person identifiers used in this report.] The report said law enforcement subsequently located C1 and returned them uninjured to staff. CCLD’s investigation involved a facility tour/welfare check, review of pertinent care and administrative records, and interviews of C1 and relevant staff and outside sources. According to C1’s LIC602 Physician’s Report: C1 was developmentally delayed and their doctor determined that they were not able to safely leave the facility unassisted. According to the Individual Service Plan (ISP) licensee authored, C1 required “constant supervision from staff.” [CONTINUED ON LIC 809-C, 1 of 2]

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2023

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 MADELEINE SOPHIES CENTER	FACILITY NUMBER: 370800930
	VISIT DATE: 02/28/2023

NARRATIVE

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[CONTINUED FROM LIC 809]

Per staff interviews and investigative records: the 01-25-2023 hiking activity occurred at an outdoor regional park/preserve. S1 was the only staff person assigned to escort/supervise three clients [C1, Client #2 (C2), and Client #3 (C3)] during the outing. As the group hiked, C1 led the pack, followed by S1, C2, and C3. When the group encountered a shallow creek, S1 asked C1 to wait. S1 then turned their back towards C1 to hold C2’s hands and help them across. When S1 turned forward again, C1 had advanced beyond their line of sight. S1, C2, and C3 tried to catch up to C1, but were unable to. Along the way, S1 asked multiple bystanders if they saw a person matching C1’s description; the bystanders confirmed they recently did. One concerned citizen observed C1 looking lost, so they had trailed C1 and phoned law enforcement. Between 30 to 60 minutes later, S1, C2, and C3 returned to the park/preserve’s parking lot and rendezvoused with C1, who was unharmed and being escorted by park rangers and police.

According to licensee’s client absentee policy, titled “Missing Consumers: Wandering or Elopement in the Community,” as soon as they were separated from C1, S1 was required to “call 911 immediately.” The policy emphasized, “There is no waiting period or minimum search time prior to contacting 911. Every minute is crucial.” S1 was also required to use their cell phone to immediately “notify the [facility’s] Program Manager” whenever a client becomes separated from the group.” According to S1’s signed, position-specific Job Description, they were required to “monitor and report any concerns related to health and safety to [their] Program Manager or [that person’s] designee.”

Per interview of S1 and corroborated by licensee’s own internal investigation: Upon realizing C1 was missing, S1 did not call 911 or alert the Program Manager (or any other coworker at the program site), despite having a working cell phone on their person during the incident. S1 confirmed knowing both phone calls were required under licensee’s absentee policy and their job description, and that the purpose of these steps was to timely enlist additional help to quickly locate C1 and ensure their safety.

[CONTINUED ON LIC 809-C, 2 of 2]

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2023

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 MADELEINE SOPHIES CENTER	FACILITY NUMBER: 370800930
	VISIT DATE: 02/28/2023

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[CONTINUED FROM LIC 809-C, 1 of 2]

CCLD determined that S1 did not follow licensee’s own absentee notification plan. One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the licensee.

An exit interview was conducted with Emerson and Carr, to whom a copy of this report, the LIC 809-D, the LIC 811 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: 02/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/02/2023 01:13 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 06/02/2023 12:42 PM

Created By: Dang Nguyen On 02/28/2023 at 11:42 AM

Link to Parent Document Below:

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 MADELEINE SOPHIES CENTER	FACILITY NUMBER: 370800930
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/28/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/01/2023 Section Cited HSC 1507.14	1 2 3 4 5 6 7	1507.14 Absentee notification plan for missing residents or participants: “Every… adult day program shall, for the purpose of addressing issues that arise when...an adult day program participant is missing from the facility, develop and comply with an absentee notification plan…”	1 2 3 4 5 6 7	Per personnel records, training records, and staff interviews: S1 received written counseling and temporary suspension on 01-26-2023 for not following licensee’s absentee notification plan. On 02-08-2023, licensee retrained its other staff on its Missing Consumers Policy. These actions resolve the deficiency.
	8 9 10 11 12 13 14	This requirement was not met, as evidenced by: Based on records and interviews, licensee did not comply with its absentee notification plan for 1 of 370 participants (C1), which posed a potential safety risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	8 9 10 11 12 13 14		8 9 10 11 12 13 14

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 Tellez

LICENSING EVALUATOR NAME:

Dang Nguyen

LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2023

LIC809 (FAS) - (06/04)

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