370804404-8-26-2022-08-AS-IESA-CHTUKU-20220831153942

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 370804404
Report Date: 08/26/2022
Date Signed: 08/26/2022 04:22:23 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
06/14/2022 and conducted by Evaluator Vicky Williamson

PUBLIC

COMPLAINT CONTROL NUMBER: 08-AS-20220614163808

FACILITY NAME:	SILVERCREST GUEST HOME		FACILITY NUMBER:	370804404
ADMINISTRATOR:	PELINA, AMALIA		FACILITY TYPE:	740
ADDRESS:	960 GROSSMONT AVENUE		TELEPHONE:	(619) 442-3957
CITY:	EL CAJON	STATE: CA	ZIP CODE:	92020
CAPACITY:	15	CENSUS: 11	DATE:	08/26/2022
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Amalia Pelina, Administrator		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Facility staff yelled at resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Vicky Williamson conducted a complaint visit to deliver findings on the above allegation. LPA was greeted and allowed entry into the facility by Amalia Pelina, Administrator, to whom the purpose of the visit was discussed.

The Department’s investigation consisted of interviews with administrator, residents, outside source, and review of records to include resident records. It was alleged that facility staff yelled at resident. Information received reported that Administrator Amalia Pelina stated, “I going to kill someone,” while in the same area where Resident 1 (R1) was sitting. Administrator denied yelling and engaging in a verbal altercation with R1. Administrator stated that she left the room to keep R1 from getting agitated. Administrator acknowledged stating, “I am going to kill someone,” however stated that the statement was a “figure of speech.” Administrator stated that she was in the kitchen area of the facility when the statement was made and there were no residents in the area at that time. Administrator stated that she would never hurt anyone. Based on interviews conducted, the Department concluded that an outside source was present and heard Administrator Amalia Pelina state, "I am going to kill someone."

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Vicky Williamson	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-20220614163808

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: SILVERCREST GUEST HOME	FACILITY NUMBER: 370804404
	VISIT DATE: 08/26/2022

NARRATIVE

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Interview conducted with R1 did not disclose that they were yelled at by Administrator Amalia Pelina. Interviews were conducted with three residents and they denied observing or hearing Administrator Amalia Pelina yell at any residents at the facility.

The Department has investigated the above-mentioned allegation that staff yelled at resident. Based upon Administrator Amalia Pelina’s own admission in stating, “I am going to kill someone,” and information received from an outside source, the preponderance of the evidence standard has been met. Therefore, the allegation is deemed substantiated.

The deficiency is noted on the attached 9099-D and is cited in accordance with the California Code of Regulations, Title 22. A copy of this report along with Licensee/Appeal Rights (LIC 9058) was provided to Administrator and the signature on this form confirms receipt of these rights.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Vicky Williamson	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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Control Number 08-AS-20220614163808

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: SILVERCREST GUEST HOME	FACILITY NUMBER: 370804404
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/26/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/16/2022 Section Cited CCR 87468.1(a)(1)	1 2 3 4 5 6 7	Personal Rights of Residents in All Facilities (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons.	1 2 3 4 5 6 7	Administrator will complete personal rights training with an outside source. Licensee will submit proof of completion of training to LPA Williamson by POC date.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on Administrator’s own admission, she stated, “I want to kill someone” while residents were present at the facility. This poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Vicky Williamson	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022

LIC9099 (FAS) - (06/04)

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