372002856-8-4-2023-18-AS-JDHS-CUPNFL-20230814102540

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 372002856
Report Date: 08/04/2023
Date Signed: 08/04/2023 12:06:52 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/01/2023 and conducted by Evaluator Tricia Danielson

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20230801112115

FACILITY NAME:	SAN DIEGO BRAIN INJURY FOUND.-HOWARD HOUSE		FACILITY NUMBER:	372002856
ADMINISTRATOR:	FLORETTA CRENSHAW		FACILITY TYPE:	735
ADDRESS:	2033 ORO VERDE ROAD		TELEPHONE:	(760) 480-7468
CITY:	ESCONDIDO	STATE: CA	ZIP CODE:	92027
CAPACITY:	8	CENSUS: 6	DATE:	08/04/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Imelda Flores, Caregiver		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Facility lacks staff to meet resident's needs
Facility is not meeting the resident's hygiene needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to initiate an investigation into the allegation listed above. LPA met with Caregiver Imelda Flores and explained the purpose of the visit. LPA spoke with Executive Director Dr. Roslyn Knox via telephone as well.
Regarding the allegation "Facility lacks staff to meet resident's needs", it was allegedly that within the last week, the overnight shift was staffed with only one staff at least once and due to the multiple floors of the facility and added duties for overnight staff, Resident #1 (R1) on the 3rd floor was left unattended while those duties were completed on other floors. Interview with Dr. Knox confirmed within the last week, there was an occasion of a overnight staff call off which resulted in only one staff on duty for the overnight shift. Dr. Knox also confirmed that the overnight staff had been recently assigned additional duties for those residents on the 1st floor. Review of R1's file revealed R1 was ambulatory, required staff to monitor food intake, was able to feed themself, displayed wandering behavior, and required constant supervision. Intverview with four (4) of four (4) staff revealed R1 can wander if left unsupervised, is not able to adhere to a required diet if unsupervised, requires constant supervision, and is ambulatory and able to feed themself. (CONTINUED ON LIC9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Tricia Danielson
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2023

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 18-AS-20230801112115

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SAN DIEGO BRAIN INJURY FOUND.-HOWARD HOUSE	FACILITY NUMBER: 372002856
	VISIT DATE: 08/04/2023

NARRATIVE

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(CONTINUED FROM LIC9099)
Regarding the allegation "Facility is not meeting the resident's hygiene needs", it was alleged that residents are not being cleaned properly after a recently implemented procedure to use a bucket of soapy water and paper towels to clean residents following a bowel movement instead of personal cleansing wipes (baby wipes). Interview with Dr. Knox reported the soapy water and paper towel procedure was discussed with staff but had yet to be implemented. During today's visit, LPA observed white plastic buckets labeled with each resident's name in either a bathroom or in the resident's room on the night stand. Facility staff showed LPA the paper towels and soap which they use for this procedure. Three (3) of four (4) staff interviewed reported the use of paper towels and soapy water is not efficiently cleaning the residents and paper towels are too rough for this procedure. One (1) staff interviewed reported the use of personal cleansing wipes would kill germs and soapy paper towels would not. Three (3) residents were interviewed but were unable to effectively communicate with LPA.
Based on LPA’s observations, interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation are found to be substantiated. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099-D.
An exit interview was conducted and a copy of this report was provided along with LIC811- Confidential Names list and Appeal Rights.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Tricia Danielson
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2023

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20230801112115

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SAN DIEGO BRAIN INJURY FOUND.-HOWARD HOUSE	FACILITY NUMBER: 372002856
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/04/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/14/2023 Section Cited CCR 80065(a)	1 2 3 4 5 6 7	Personnel Requirements- (a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The licensee will submit a written statement detailing a back up plan in the event an overnight staff calls off. Proof of such plan to be submitted to LPA by POC due date 8/18/2023.
	8 9 10 11 12 13 14	The licensee did not ensure personnel requirements were maintained. Based on interviews and records reviewed, the overnight shift was recently staffed with only 1 staff preventing them from providing supervision to R1 while attending to other residents. This poses a potential health,	8 9 10 11 12 13 14	(continued from left) safety, and personal rights risk to clients in care.
Type B 08/14/2023 Section Cited CCR 80077.4(b)(1)	1 2 3 4 5 6 7	Care for Clients with Incontinence -(b) If a licensee...retains a client who has bowel and/or bladder incontinence, the licensee is responsible for...:(1) Ensuring that incontinent care products appropriate to the needs of the client are used whenever they are needed. This requirement was not met as	1 2 3 4 5 6 7	As per conversation with Dr. Knox, the recent change to cleaning clients with soapy paper towels rather than personal cleansing wipes will be discontinued by POC due date of 8/14/2023.
	8 9 10 11 12 13 14	evidenced by: The licensee did not ensure proper incontinence care was provided to clients. Based on interviews, 3 of 4 staff interviewed stated clients are not getting effective hygiene with the use of paper towels and soapy water. This poses a potential health, safety, and personal rights	8 9 10 11 12 13 14	(continued from left) to clients in care.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Tricia Danielson
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2023

LIC9099 (FAS) - (06/04)

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