372004738-7-13-2023-08-AS-SJAB-CU2TC6-20230724143614

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 372004738
Report Date: 07/13/2023
Date Signed: 07/13/2023 01:16:35 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 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
06/12/2020 and conducted by Evaluator Daniel Pena

COMPLAINT CONTROL NUMBER: 08-AS-20200612145057

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: 107	DATE:	07/13/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Vonda Boller, Administrator		TIME COMPLETED:	11:20 AM

ALLEGATION(S):

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Lack of supervision resulting in inappropriate interactions between residents

INVESTIGATION FINDINGS:

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On 7/13/2023, at about 09:30 AM, Licensing Program Analyst (LPA), Daniel Pena visited the facility to conclude a complaint investigation. LPA was met at the entrance by Administrator, Vonda Boller. After introducing and identifying himself, LPA was allowed inside the facility. LPA discussed the purpose of the visit and elements of the complaint with Ms. Boller.

On 6/12/2020, Community Care Licensing Division (CCLD) received this complaint which alleged lack of supervision resulted in inappropriate interactions between residents. The Department’s investigation consisted of facility tour, record reviews and interviews with pertinent staff. Per record review and interviews, on 6/11/2020, Resident 1 (R1) and Resident 2 (R2) were in their shared room when R2 grabbed R1 by the arms. R2 yelled at R1 and twisted their arms behind their back. Later this same day, R1 reported the incident to nursing staff. According to reports, R1 was visually shaken and upset. Interviews revealed that R2 admitted to striking R1 in the face with a hand.

Reports and interviews indicate that staff escorted R2 to a separate part of the facility. R2's demeanor was described by staff as confused.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023

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 08-AS-20200612145057

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: CANYON VILLAS	FACILITY NUMBER: 372004738
	VISIT DATE: 07/13/2023

NARRATIVE

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Police were called due to the incident. LPA reviewed the police call logs and event documentation related to the incident. Records reflect that neither party was arrested as a result of the incident. At the time of this incident, R2 did not have a Dementia diagnosis but was demonstrating confusion and agitation. Records reflect that officers did not take R2 to an emergency psychiatric facility for evaluation. Facility staff contacted R2’s primary care physician and responsible person. R2's responsible person contacted R2's PCP to request a psychiatric evaluation. On this same day, R2 was evaluated and diagnosed with Dementia.

Documentation related that nurses at the facility evaluated R1 and R2 and neither was observed to have any physical injuries. R2 later transferred to a Memory Care facility and R1 remained at Canyon Villas. Both residents lived in the Independent Living portion of the facility and shared an apartment. Because the incident occurred in their apartment there were no witnesses present. Interviews indicated that there was no lapse in supervision as R1 was receiving assistance at the apartment. Interviews related that staff generally have 10-12 interactions with residents receiving care during a 24 hour period. Interviews and records did not show any other emergencies occurring on the same day of this incident. Interviews also note that there were no previous similar incidents between the residents.

Records reflect that once R1 reported the incident to the facility, staff reacted and assisted the residents. Appropriate notifications were sent to law enforcement, resident's responsible person, and the resident’s physicians. Once it was determined by evaluation and re-assessment that R2 required a higher level of care, the facility coordinated a transfer to a memory care facility.

The Department has investigated the allegations, which included LPA observation and facility and outside source record reviews. Due to a lack of corroborating evidence obtained during the investigation, the allegations are Unsubstantiated. This finding means that although the allegations may have happened or may be valid, there is not a preponderance of evidence to prove they occurred.

An exit interview was conducted with Ms. Boller, and a copy of this report was provided to Ms. Boller, whose signature below confirms receipt of copies of this report and Licensee Rights (LIC 9058).

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023

LIC9099 (FAS) - (06/04)

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