370804404-1-25-2023-08-AS-JRAE-CNM2PQ-20230131163444

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 370804404
Report Date: 01/24/2023
Date Signed: 01/25/2023 07:53:53 AM

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
10/05/2020 and conducted by Evaluator Tiffany Holmes

COMPLAINT CONTROL NUMBER: 08-AS-20201005102616

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: 0	DATE:	01/24/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Amalia Pelina, Administrator		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Lack of supervision resulting in client AWOL

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced visit to close out a complaint. LPA identified herself, was granted entry, and stated the purpose of the visit to Amalia.

During the investigation, LPA toured the facility, conducted interviews with staff and residents and collected pertinent paperwork. In speaking with staff, LPA discovered that Client 1 (C1) left the facility on Septemebr 24, 2020 and was returned on or around October 4 2020. C1 was found in Los Angeles by LAPD. Interviews revealed once they found C1 and took them to the mental health facility, from there C1 called their mother. While C1 was at the hospital, interviews revealed that the case manager from the hospital in Los Angeles contacted C1s case manager in San diego and they arranged for C1 to get back to San Diego. Interviews revealed once C1 returned they went to the hospital here in San Diego.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR NAME: Tiffany Holmes	TELEPHONE: (619) 481-0843
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2023

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-20201005102616

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: 01/24/2023

NARRATIVE

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According to C1s physician report dated February 15,2020 C1 is not able to leave the facility unassisted. Interviews with outside sources state the client has a history of AWOL and is a high risk to do it. Interviews with staff revealed they waited two hours to report C1 missing knowing that C1 is a high risk to AWOL. At the time C1 moved in the administrator was made aware of C1s high risk of AWOLing.

Based on the evidence obtained from interviews, records review, the complaint allegation is substantiated.

An exit interview was conducted with Amalia Pelina, Administrator and a copy of this report along with Licensee/Appeal Rights (LIC 9058 03/22) was provided via US Mail.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR NAME: Tiffany Holmes	TELEPHONE: (619) 481-0843
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20201005102616

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: 01/24/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/24/2023 Section Cited CCR 80078(a)	1 2 3 4 5 6 7	Responsibility for Providing Care and Supervision. The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Facility is closed and no longer operating
	8 9 10 11 12 13 14	Licensee did not provide supervison for 1 out of 14 residents. On xx/xx/xxxx C1 AWOL'd and was found in Los Angeles. This poses an immediate risk to clients 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) 767-2301
LICENSING EVALUATOR NAME: Tiffany Holmes	TELEPHONE: (619) 481-0843
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2023

LIC9099 (FAS) - (06/04)

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