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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 372004561
Report Date: 09/26/2022
Date Signed: 09/26/2022 03:54:40 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
12/03/2021 and conducted by Evaluator Rebecca A Ruiz
COMPLAINT CONTROL NUMBER: 08-AS-20211203135402
FACILITY NAME:MAILE ALOHAFACILITY NUMBER:
372004561
ADMINISTRATOR:PEREZ, JOSEPHINE A.FACILITY TYPE:
740
ADDRESS:3636 CHRISTINE STREETTELEPHONE:
(858) 274-0921
CITY:SAN DIEGOSTATE: CAZIP CODE:
92117
CAPACITY:12CENSUS: 8DATE:
09/26/2022
UNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Cleo ManzieTIME COMPLETED:
03:55 PM
ALLEGATION(S):
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Licensee yelled at resident
Licensee did not allow visitation
Licensee did not allow resident to leave the facility
Licensee did not allow resident to attend a medical appointment
Illegal Eviction
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced complaint investigation visit to deliver findings regarding the above-mentioned allegations. LPA identified herself to, was greeted by, and explained the purpose of the visit to Caregiver Cleo Manzie. Licensees Josephine and Orlando Perez arrived during the visit.

The Department’s investigation consisted of interviews with staff, residents, and outside sources, review of records, and a tour of the facility. It was alleged that the Licensee yelled at a resident. Interviews with the Licensees and outside sources revealed that on or around December 2021, the Licensees Orlando and Josephine Perez and Resident 1 (R1) were having a conversation regarding COVID guidance when Licensee Orlando Perez raised his voice while speaking to R1. Interviews revealed that Licensee Orlando Perez later apologized to R1 for the incident.

Continued on LIC9099-C page.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2022
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 6
Control Number 08-AS-20211203135402
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: MAILE ALOHA
FACILITY NUMBER: 372004561
VISIT DATE: 09/26/2022
NARRATIVE
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It was alleged that the Licensee did not allow residents to leave the facility, attend medical appointments, or allow visitation. Record review of the Provider Information Notice (PIN) 21-40-ASC revealed that the visitation guidance at that time required that individuals requesting an indoor visitation are required to show either proof of COVID-19 vaccination or proof of a negative COVID-19 test taken within 72 hours. Visitors requesting an outdoor visit were not required to show proof of COVID-19 vaccination or negative COVID-19 test. PIN 21-40-ASC was in effect from August 27, 2021 to January 18, 2022. Interviews and records review revealed that on or around September 2021, the Licensee Josephine Perez told family members of residents that indoor and outdoor visitation was not allowed per COVID-19 guidance from Community Care Licensing (CCL). Interviews with family members revealed that they were not able to visit their family members at the facility. During a visit on 12/9/2021, LPA Ruiz observed a visitor was allowed into the facility. Interviews with the Licensees, residents, and outside sources revealed that R1 was not vaccinated for COVID-19 and was told by Licensee Josephine Perez that R1 would have to quarantine in R1’s room for 14 days if they left the facility, regardless of COVID-19 exposure. PIN 21-17.2-ASC stated that “residents have the right to leave facilities for outing” and are not required to be quarantined after returning from an outing unless they had a close contact with someone who tested positive for COVID-19. PIN 21-17.2-ASC was in effect from May 14, 2021 to January 18, 2022. Interviews with residents and outside sources revealed that R1 did not leave the facility for personal outings and medical appointments because of the potential 14-day quarantine. Interviews and records review revealed that R1 had a medical appointment on 11/18/2021 and the Licensee informed R1’s family that a fully vaccinated individual or an individual who received a negative COVID test needed to take R1 to the medical appointment and that the Licensee offered transportation services to R1 but R1 refused. As a result, R1’s family member canceled R1’s medical appointment.

It was alleged that the Licensee unlawfully evicted R1. Review of records revealed that on 11/15/2021, Licensee Josephine Perez told R1’s responsible party that a fully vaccinated individual or an individual who had received a negative COVID test would be required to transport R1 to a medical appointment and if R1 and R1’s responsible parties could not follow those guidelines, the Licensee would “consider this as the beginning of [R1’s] 30-day notice”. Records revealed that on or around 12/3/2021, the Licensee Josephine Perez told R1’s responsible party that R1 had verbally given the Licensee a 30-day notice to move out. Interviews with the Licensees stated that R1’s responsible party provided a 30-day move out notice, which conflicted with the records reviewed during the investigation. Interviews with the Licensees and outside sources revealed that R1 moved out of the facility on or around the end of December 2021.
Continued on LIC-9099-C page.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 08-AS-20211203135402
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: MAILE ALOHA
FACILITY NUMBER: 372004561
VISIT DATE: 09/26/2022
NARRATIVE
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Based on the evidence obtained during the investigation, the Department has found that the Licensee yelled at a resident, did not allow visitation, did not allow resident to leave the facility, did not allow resident to attend a medical appointment, and illegally evicted R1. Therefore, the allegations are deemed substantiated, which means that the preponderance of the evidence standard has been met and the allegations are valid. The following deficiencies were cited per CA Code of Regulations Title 22 and noted on the attached LIC9099-D page.

An exit interview was conducted with Licensees Josephine and Orlando Perez, to whom a copy of this report and the Licensee Appeal Rights (LIC9058 01/16) were provided via hard copy.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 08-AS-20211203135402
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: MAILE ALOHA
FACILITY NUMBER: 372004561
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/26/2022
Section Cited
CCR
87468.1(a)(1)
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87468.1 Personal Rights of Residents in All Facilities (a) residents... shall have all of the following personal rights: (1) to be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement has not been met as evidenced by:
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Licensees stated they will attend a outside vendor training on personal rights and submit a proof of attendance for Licensees and staff by POC due date.
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Based on record review, observations, and interviews, the Licensee did not treat R1 with dignity. This poses a personal rights risk to 12 of 12 residents in care.
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Type B
10/26/2022
Section Cited
CCR
87468.1(a)(11)
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87468.1 Personal Rights of Residents in All Facilities (a) residents… shall have all of the following personal rights: (11) to have their visitors… permitted to visit privately during reasonable hours and without prior notice… This requirement has not been met as evidenced by:
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Licensees stated they send letters to residents and their families on the current visitation guidance and will attend an outside vendor training on visitation and submit proof of attendance for Licensees and staff and a copy of the letter by POC date.
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Based on record review, observations, and interviews, the Licensee did not allow R1 to have outdoor visitation. This poses a personal rights risk to 12 of 12 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: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 08-AS-20211203135402
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: MAILE ALOHA
FACILITY NUMBER: 372004561
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/26/2022
Section Cited
CCR
87468.1(a)(6)
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87468.1 Personal Rights of Residents in All Facilities (a) residents… shall have all of the following personal rights: (6) to leave or depart the facility at any time and to not be locked in any room, building, or on facility premises by day or night… This requirement has not been met as evidenced by:
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Licensees stated they will attend a outside vendor training on outings and submit a proof of attendance for Licensees and staff by POC due date.
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Based on record review, observations, and interviews, the Licensee did not allow R1 to leave the facility for outings. This poses a personal rights risk to 12 of 12 residents in care.
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Type B
10/26/2022
Section Cited
CCR
87468.1(a)(16)
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87468.1 Personal Rights of Residents in All Facilities (a) residents… shall have all of the following personal rights: (16) to receive or reject medical care or other services. This requirement has not been met as evidenced by:
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Licensees stated they will attend a outside vendor training on attending medical appointments and submit a proof of attendance for Licensees and staff by POC due date.
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Based on record review, observations, and interviews, the Licensee did not allow R1 to attend medical appointments. This poses a personal rights risk to 12 of 12 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: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 08-AS-20211203135402
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: MAILE ALOHA
FACILITY NUMBER: 372004561
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/26/2022
Section Cited
CCR
87468.2(a)(20)
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Additional Personal Rights of Residents in Privately Operated Facilities (a)(20) to be protected from involuntary transfers, discharges, and evictions. A licensee shall not involuntarily transfer or evict residents for reasons other than those permitted by state law or regulations...
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Licensees stated they will attend a outside vendor training on eviction procedures and submit a proof of attendance for Licensees and staff by POC due date.
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This requirement has not been met as evidenced by:
Based on record review and interviews, the Licensee unlawfully evicted R1 and gave R1 an unlawful verbal 30-day eviction notice. This poses a personal rights risk to 12 of 12 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: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6