372004738-10-13-2021-08-AS-SJAB-C86VD4-20211026162008

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 372004738
Report Date: 10/13/2021
Date Signed: 10/13/2021 04:13:08 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
07/26/2021 and conducted by Evaluator Alexandre Vo

COMPLAINT CONTROL NUMBER: 08-AS-20210726155900

FACILITY NAME:	CANYON VILLAS		FACILITY NUMBER:	372004738
ADMINISTRATOR:	RICHARD JOHN ROWE		FACILITY TYPE:	740
ADDRESS:	4282 BALBOA AVENUE		TELEPHONE:	(858) 273-1306
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92117
CAPACITY:	133	CENSUS: 88	DATE:	10/13/2021
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Business Director, Vonda Boller		TIME COMPLETED:	01:50 PM

ALLEGATION(S):

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Facility is not taking necessary precautions to prevent the spread of COVID-19.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Alexandre Vo, conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegation. LPA was allowed entry into the facility after identifying himself and stating the purpose of the visit. LPA met with Business Director, Vonda Boller.

The facility has an approved Mitigation Plan Report as of February 22, 2021 by LPA, James Santos. During the complaint visit on August 2, 2021, LPA Vo observed the facility was undergoing repainting and some signs and boards were taken down. LPA observed there were appropriate signage regarding COViD-19 on the bulletins that were to be replaced onto the walls. A tour was conducted of the facility to include the dining area and LPA observed the following: signs throughout the facility regarding checking in at the front desk, hand sanitizer available to the residents, symptom screening at the check-in, residents were encouraged to wear masks. LPA observed a vaccine verification book for visitors. LPA also observed the isolation area on the third floor with reserved isolation rooms for sick residents that were unoccupied at the time.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Alexandre Vo	TELEPHONE: (619) 385-7506
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021

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 08-AS-20210726155900

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: 10/13/2021

NARRATIVE

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At or around 2:30 PM, in the lobby area were three female residents and two maintenance staff. The female residents were sitting on a couch and conversing. LPA observed a maintenance worker's mask on the chin and did not cover the nose or mouth. When LPA and the Director toured the food service area, there were two kitchen staff not wearing masks. According to PIN 21-12-ASC issued on February 10, 2021 and the facility's Mitigation Plan Report, all Adult and Senior Care staff are required to wear a face-covering on facility premises. Allegation is deemed substantiated due to the preponderance of the evidence standard has been met. A citation is being issued in accordance with California Code of Regulations, Title 22, and listed on the 9099D.

An exit interview was conducted with the Business Director and a Plan of Correction was developed. A copy of this report and Appeal Rights (9058 01/16) were provided to the Business Director by electronic mail. A confirmation receipt was requested from the Business Director upon receipt of the documents.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Alexandre Vo	TELEPHONE: (619) 385-7506
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 08-AS-20210726155900

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: 10/13/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/15/2021 Section Cited CCR 87307(d)(2)	1 2 3 4 5 6 7	87307 Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities: (2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Business director agreed to review current masking guidance with all staff members and agreed to provide a roster of staff that attended the training. Business director will provide the training roster/material to LPA by POC date.
	8 9 10 11 12 13 14	Based on observations, facility staff did not provide a safe and healthful environment to the residents in care. This poses a potential health risk to all residents.	8 9 10 11 12 13 14
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	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Alexandre Vo	TELEPHONE: (619) 385-7506
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021

LIC9099 (FAS) - (06/04)

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