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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 372002165
Report Date: 12/29/2022
Date Signed: 12/29/2022 11:59:17 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
07/29/2021 and conducted by Evaluator Natasha Persaud
COMPLAINT CONTROL NUMBER: 08-AS-20210729160048
FACILITY NAME:CABANAS ADULT CARE HOMEFACILITY NUMBER:
372002165
ADMINISTRATOR:CABANAS, ERLOVEFACILITY TYPE:
740
ADDRESS:8031 MONTARA AVENUETELEPHONE:
(858) 689-1872
CITY:SAN DIEGOSTATE: CAZIP CODE:
92126
CAPACITY:0CENSUS: DATE:
12/29/2022
UNANNOUNCEDTIME BEGAN:
11:47 AM
MET WITH:TIME COMPLETED:
11:48 AM
ALLEGATION(S):
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Staff hit resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Natasha Persaud concluded the investigation regarding the above mentioned allegation. The facility was closed, and the reports were sent via certified mail.

During the investigation, a virtual tour was conducted, records requested and interviews with staff, residents, and outside sources. It was alleged staff hit a resident. It was reported the administrator hit Resident #1 (R1) in the stomach and hand for entering the kitchen on 07/08/21. It was also reported the administrator hit R1 again in the stomach on 07/27/21. Then on 07/28/21 the administrator took R1 to the store to buy R1 their favorite items as an apology but also apologized to R1. R1 is ambulatory and has a Major Neurocognitive Disorder. The administrator’s interview revealed R1 came into the kitchen as the stove was on and R1 attempted to touch the heat source. Therefore, the administrator hit R1’s hand out of the way for their safety and told R1 to leave the kitchen. The administrator stated he did not hit R1 in a hard manor, it was a quick reaction. The administrator’s interview revealed he apologized to R1 and did take her the store to buy her some favorite items as an apology. Resident interviews revealed not witnessing any of the occurrences. Staff interviews also revealed not being aware of the occurrences. Continued on an LIC 9099C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022
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-20210729160048
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: CABANAS ADULT CARE HOME
FACILITY NUMBER: 372002165
VISIT DATE: 12/29/2022
NARRATIVE
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Outside source interviews revealed local law enforcement was contacted and followed up at the facility. The police report was requested for the incident. However, law enforcement had no documentation on file for the incident.

Based on interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 8 is being cited on the attached LIC 9099D. A copy of this report was mailed certified to the licensee.

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20210729160048
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: CABANAS ADULT CARE HOME
FACILITY NUMBER: 372002165
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/29/2022
Section Cited
CCR
87468.1(a)(1)
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Personal Rights of Residents in All Facilities. To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by:
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Deficiency cleared by evidence of facility closure.
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Based on interviews, the licensee did not ensure (R1) 1 out of 5 residents were treated with dignity, when the administrator hit R1 on the hand. This posed a personal rights violation to residents in care.
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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 TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3