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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 372004738
Report Date: 03/26/2021
Date Signed: 03/26/2021 05:20:14 PM



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
12/31/2019 and conducted by Evaluator Laarni Santiago
COMPLAINT CONTROL NUMBER: 08-AS-20191231140620
FACILITY NAME:CANYON VILLASFACILITY NUMBER:
372004738
ADMINISTRATOR:RICHARD JOHN ROWEFACILITY TYPE:
740
ADDRESS:4282 BALBOA AVENUETELEPHONE:
(858) 273-1306
CITY:SAN DIEGOSTATE: CAZIP CODE:
92117
CAPACITY:133CENSUS: 94DATE:
03/26/2021
UNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Vonda Boller, Business DirectorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff neglect resulted in R1’s fall that led to hospitalization.
Staff omitted information on the incident report.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Laarni Santiago conducted an unannounced complaint investigation tele-visit via video conferencing due to COVID-19. LPA met with Business Director, Vonda Boller, identified herself, and discussed the purpose of the tele-visit, which was to deliver findings for the above allegations.

The Department’s investigation included, but was not limited to, interviews with staff and outside sources. Facility and medical records were also obtained by the Department and reviewed for pertinent evidence.

The Department received a complaint alleging that staff neglect resulted in Resident 1’s (R1) (See LIC 811 Confidential Names List for R1) fall that led to hospitalization. Interviews revealed that due to R1’s health condition, they had limited mobility with left hand contracture. On April 5th 2019, during incontinence care, Staff 1 (S1) (See LIC 811 Confidential Names List for S1) turned R1 to their left side in order to clean bowel movement. However, when S1 walked away to grab wipes, R1’s leg uncrossed and rolled off on the other
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 318-5974
LICENSING EVALUATOR NAME: Laarni SantiagoTELEPHONE: (619) 318-5974
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2021
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-20191231140620
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: CANYON VILLAS
FACILITY NUMBER: 372004738
VISIT DATE: 03/26/2021
NARRATIVE
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side of the bed, with shoulder caught in the railing, as they slid down with their feet hitting the ground. Upon observing this, S1 ran towards R1 to catch them while sliding off the bed to keep them from hitting the ground hard. R1 incurred a minor injury from the fall and expressed pain that led to hospitalization but discharged back to the facility on the same day. Medical records revealed that R1 sustained an abrasion, shoulder contusion with left knee and left hip joint pain. There were no serious bodily injury or fracture noted on the medical records. Interviews conducted with staff and outside sources revealed that R1 is a two-person assist due to their health condition and limited mobility. Furthermore, S1 acknowledged that R1 was a two-person assist but failed to secure their safety by not requesting assistance from other caregivers. Evidence from the investigation revealed that staff failed to take the appropriate steps to secure R1’s safety by not requesting assistance from other staff when they acknowledged that R1 is a two-person assist.

The Department also investigated the allegation that staff falsified the incident report regarding R1’s fall that occurred on April 5th, 2019. Interviews conducted with pertinent witnesses revealed that during incontinence care, R1 rolled off on the side of the bed when S1 walked away to grab cleaning wipes. While R1 slid off the bed, S1 ran to catch them while sliding off the bed, placed them on the floor and alerted another staff on shift to come and assist. A review of the incident report dated April 5th, 2019 notes that “a staff was called to R1’s room. When staff arrived, R1 was found on the floor yelling for help and expressed pain all over their body. Laceration on left and right elbow was observed, as well as redness on left and right knees.” However, it was discovered that the incident report did not include the full the nature of the incident and omitted that R1 had a witnessed fall during incontinence care when S1 walked away to grab wipes.

This agency has investigated the aforementioned allegations. Based on LPA's evidence obtained from interviews, records review, and outside sources, the preponderance of the evidence standard has been met, therefore the above-mentioned allegations are found to be Substantiated. Citations are being issued in accordance with California Code of Regulations, Title 22, and are listed on the LIC9099D.

An exit interview was conducted with Vonda Boller, and a copy of this report, and Licensee's Rights (LIC 9058 01/16) were emailed to Administrator; an email read receipt confirms receipt of these documents.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 318-5974
LICENSING EVALUATOR NAME: Laarni SantiagoTELEPHONE: (619) 318-5974
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20191231140620
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: CANYON VILLAS
FACILITY NUMBER: 372004738
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/26/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
03/27/2021
Section Cited
CCR
87411(a)
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Personnel Requirements – General: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs…
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An in-service training will be performed with all staff regarding two-person assist. The Licensee will submit a proposed date of this in-service to CCLD by POC due date, 03/29/2021. Once completed, copies of this in-service will be submitted to CCLD as well.
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This requirement was not met based on evidence by: Based on interviews and records review, licensee did not ensure S1 provided the services necessary to meet R1' needs. This posed an immediate health and safety risk to the residents in care.
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Request Denied
Type B
04/09/2021
Section Cited
CCR
87211(a)(1)
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 Reporting Requirements: A written report shall be submitted to the licensing agency... This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.
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An updated incident report was provided to the Department to reflect the accurate nature of the incident that occurred on 04/05/2019. In addition, an in-service training for staff will be performed regarding reporting requirements. The Licensee will submit proof of in-service training on or before 04/09/2021.
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This requirement was not met based on evidence by: Based on interviews and a review of facility’s incident report, the licensee did not provide a full scope of the nature of the incident involving R1.
This impacted the facility’s plan of operation.
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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: Simon JacobTELEPHONE: (619) 318-5974
LICENSING EVALUATOR NAME: Laarni SantiagoTELEPHONE: (619) 318-5974
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2021
LIC9099 (FAS) - (06/04)
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