370804823-6-19-2025-08-AS-HHUL-DN4VNE-20251104153500

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 370804823
Report Date: 06/19/2025
Date Signed: 06/19/2025 01:53:21 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
10/03/2024 and conducted by Evaluator Juliana Barfield

COMPLAINT CONTROL NUMBER: 08-AS-20241003144505

FACILITY NAME:	ST. PAUL'S VILLA		FACILITY NUMBER:	370804823
ADMINISTRATOR:	ELEANOR DOWNING		FACILITY TYPE:	740
ADDRESS:	2340 FOURTH AVENUE		TELEPHONE:	(619) 232-2996
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92101
CAPACITY:	200	CENSUS: 109	DATE:	06/19/2025
		UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Director of Nursing Divina Salinas		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Neglect/Lack of Supervision resulting in serious bodily injuries.

Neglect resulting in delayed medical care.

Neglect resulting in UTI/Sepsis.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Juliana Barfield conducted an unannounced subsequent complaint visit regarding the above-mentioned allegations. LPA was met by, identified herself to, and discussed the purpose of the visit with Director of Nursing Divina Salinas. The Department's investigation consisted of records reviews and interviews with staff and outside sources.

It was alleged that St. Paul’s Villa (facility) staff had neglect and lack of supervision that resulted in serious bodily injuries for Resident (R1). It was also alleged that there was staff neglect in delayed medical care and that licensee did not provide incontinent care. Based on records reviews and interviews, R1 sustained injuries from an unwitnessed fall at approximately 7:00pm on 08/20/24 during an altercation with another resident (R2). The residents were in front of the nursing station room where staff were working. The charge nurse immediately assessed R1 who complained of pain to the back of the head and buttocks. Staff called paramedics and notified R1’s Durable Power of Attorney (DPOA). The DPOA came onsite when the paramedics were at the facility and signed a release to deny transfer of R1 by paramedics to the hospital.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Juliana Barfield
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025

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-20241003144505

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ST. PAUL'S VILLA	FACILITY NUMBER: 370804823
	VISIT DATE: 06/19/2025

NARRATIVE

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DPOA instructed staff to monitor R1 and if the pain worsens to give Tylenol and then if needed, the DPOA would take R1 to the hospital in the morning.

On 8/21/24 at 7:00am, R1 had an unwitnessed fall in the dining room where R1 slipped out of a chair while sitting down to eat breakfast. Staff were in dining room and assisted R1 off the floor. According to records reviews, this type of fall of slipping out of a bed or chair was not uncommon for R1, however this time R1 complained of pain and was not able to bear weight without assistance. R1’s DPOA was onsite at the facility at that time and drove R1 to the hospital. R1 was diagnosed with a closed fractured sacrum and a closed fracture to the left ischium. ER doctor prescribed Tylenol for R1's pain and R1 returned to facility. Based on records reviews and interviews, there is not substantial evidence to support the allegation that staff had neglect and lack of supervision that resulted in serious bodily injuries for R1, therefore this allegation is unsubstantiated.

It was alleged that the staff did not seek timely medical care for R1. Based on records reviews and interviews, staff called paramedics to transfer R1 to the hospital after the fall on 8/20/24. R1’s DPOA signed a paramedic release form denying transport of R1 by paramedics to the hospital. DPOA then instructed staff to monitor R1 and if the pain worsened, the DPOA would take R1 to the hospital in the morning. DPOA was notified in the morning of 08/21/25 that R1 slipped out of chair while sitting down for breakfast. This type of slipping fall was not uncommon for R1, however this time R1 complained of pain and was not able to bear weight without assistance. Shortly after the incident, the DPOA drove R1 to the hospital emergency room. R1 was diagnosed with a closed fractured sacrum and a closed fracture to the left ischium. The ER doctor prescribed Tylenol for R1's pain and R1 returned to facility. Based on records reviews and interviews, there is not substantial evidence to support the allegation that staff did not seek timely medical care for R1.

It was alleged that licensee did not provide R1 incontinence care. Records reviews and interviews indicated that R1 was paying $700/month additional to the monthly payment rate since admission to facility on 06/19/24. R1’s Incontinence Care Plan stated that staff would assist R1 with all toileting needs. Facility staff and nurses used a 24-hour charting system that documented toileting. The charting was available for incoming staff to checked at the beginning of shifts. Examples of entries during a shift are: On 07/30/24 staff assisted R1 with toileting, staff changed his clothes, and staff escorted R1 to breakfast at 06:45am. On 08/15/24, resident was awake at 1:28am and staff assisted him to the restroom and back to bed.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Juliana Barfield
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20241003144505

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ST. PAUL'S VILLA	FACILITY NUMBER: 370804823
	VISIT DATE: 06/19/2025

NARRATIVE

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08/16/24, R1 urinated on door right after staff had changed resident. Staff changed R1 again and changed bed sheets. Based on record review, there is not substantial evidence to support the allegation that staff did not provide incontinence care, therefore this allegation is unsubstantiated.

An exit interview was conducted with Divina Salinas, to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22) were provided. Her signature on this form acknowledges receipt of these rights.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Juliana Barfield
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025

LIC9099 (FAS) - (06/04)

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