370804165-8-29-2022-08-AS-SJAB-CHTPAK-20220831110854

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 370804165
Report Date: 08/26/2022
Date Signed: 08/29/2022 02:32:34 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 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
10/14/2020 and conducted by Evaluator Daniel Pena

COMPLAINT CONTROL NUMBER: 08-AS-20201014130330

FACILITY NAME:	GOOD SAMARITAN BOARD AND CARE FACILITY		FACILITY NUMBER:	370804165
ADMINISTRATOR:	FAYE MAYO		FACILITY TYPE:	740
ADDRESS:	6255 MCHANEY COURT		TELEPHONE:	(619) 267-2445
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92114
CAPACITY:	6	CENSUS: 6	DATE:	08/26/2022
		UNANNOUNCED	TIME BEGAN:	03:10 PM
MET WITH:	Angelita Sanchez, Administrator		TIME COMPLETED:	03:50 PM

ALLEGATION(S):

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Staff are not meeting the needs of the resident.
Staff do not assist the resident with dental care.
Staff are misplacing the residents belongings.
Staff are not following resident's special diet.
Non ambulatory resident is listed as ambulatory on the facility emergency plan.

INVESTIGATION FINDINGS:

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On 08/26/2022, at about 3:10 PM, Licensing Program Analyst (LPA) Daniel Pena conducted an unannounced complaint investigation visit to the facility to deliver findings on the above-mentioned allegations. LPA identified himself and was granted entry into the facility by Administrator, Angelita Sanchez. LPA met with Administrator Sanchez to discuss the purpose of today’s visit.

The Department’s investigation into this complaint consisted of interviews with residents, staff, outside sources and review of facility records. It was alleged staff did not meet Resident 1’s needs, did not provide assistance with dental care, misplaced Resident 1’s belongings, did not follow Resident 1’s special diet and listed Resident 1 on facility documents as ambulatory when they were non-ambulatory.
Documents show that Resident 1 resided at the Good Samaritan Board and Care Facility from June 2, 2020 until they passed on January 28, 2021. Resident 1 was diagnosed with Metabolic Encelopathy; unspecified Dementia without behavioral disturbance; Type 1 Diabetes; chronic diastolic (congestive) and chronic Stage 3 kidney disease.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022

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-20201014130330

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: GOOD SAMARITAN BOARD AND CARE FACILITY	FACILITY NUMBER: 370804165
	VISIT DATE: 08/26/2022

NARRATIVE

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Records reflect Resident 1 required assistance with all Activities of Daily Living. A review of Resident 1’s medication administration records illustrated that staff consistently gave Resident 1’s medications without any lapses. Interviews with residents reported no complaints in the level of care or responsiveness by staff. Staff interviews revealed that Resident 1 had severe Dementia and required a high level of attention. Staff said they followed the prescribed care plan, which included Resident 1’s special diet plan. Facility staff did not recall Resident 1 reporting to them that they lost personal property. Facility staff denied ever taking or losing any of Resident 1’s personal belongings. Staff also said they brushed Resident 1’s teeth in the morning and before they went to bed.

An interview with Resident 1’s responsible party reported stated that Resident 1 had Dementia, Type 1 Diabetes and suffered from short term memory loss. This interview revealed that Resident 1 was not always truthful and complained to staff a lot. The responsible party said facility staff always met Resident 1’s needs, kept the facility clean and fed Resident 1 well. Responsible party advised that staff placed a bell in Resident 1’s room to call for assistance. However, the responsible party said staff had to take it every once in a while, because Resident 1 was disruptive and constantly ring the bell. Resident 1’s responsible party was never concerned that staff were not responsive to Resident 1’s needs. The responsible party also stated that Resident 1 brushed their own teeth regularly. The responsible party advised staff that Resident 1 could do it themselves and encouraged staff to let Resident 1 do things for themselves. Responsible party said facility staff followed their guidance.

Responsible party said Resident 1 never complained of personal property being stolen or lost. Responsible party stated that staff strictly followed Resident 1’s diet plan. Interviews yielded that Resident 1 was a vegetarian by choice but did eat chicken and fish. No red meat. When asked, this source said Resident 1 preferred fish but could eat chicken and it was part of their diet plan. The responsible party also said staff took great care in caring for chronic sores on Resident 1’s hip and foot. The responsible party said Resident 1 was non-ambulatory and they never saw any facility record documenting that Resident 1 was ambulatory. After reviews of facility documentation and interviews of staff, residents and outside sources there is insufficient information to support the allegations.

Based on the evidence obtained during this investigation, the aforementioned allegations are found to be UNSUBSTANTIATED, meaning that although the allegations may have happened or may be valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted with Administrator Sanchez; a copy of this report and Licensee's Rights (LIC9058) were provided to Administrator Sanchez.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022

LIC9099 (FAS) - (06/04)

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