372004738-8-29-2023-08-AS-DPOL-CV8S6B-20230831133540

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 372004738
Report Date: 08/29/2023
Date Signed: 08/29/2023 03:36:43 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
03/22/2023 and conducted by Evaluator Sabel Martinez

COMPLAINT CONTROL NUMBER: 08-AS-20230322131219

FACILITY NAME:	CANYON VILLAS		FACILITY NUMBER:	372004738
ADMINISTRATOR:	BOLLER, VONDA		FACILITY TYPE:	740
ADDRESS:	4282 BALBOA AVENUE		TELEPHONE:	(858) 273-1306
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92117
CAPACITY:	133	CENSUS: 106	DATE:	08/29/2023
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Executive Director, Vonda Boller		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff did not perform proper resident wound care
Staff did not ensure an incontinent resident was kept clean
Staff did not give resident medication as directed by the physician

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced complaint investigation visit to deliver findings. The LPA introduced himself and disclosed the purpose of the visit to Executive Director, Vonda Boller.

Throughout the investigation, the Department secured pertinent records and conducted interviews with internal and external sources.

It was alleged staff did not perform proper resident wound care. It was reported to the Department an outside source had witnessed Resident # 1 (R1) with a soiled and dislodged bandages on several occasions. Interviews with staff, residents and external sources, including R1, revealed the facility staff did assist R1 with changing soiled and dislodged bandages. It was also revealed R1 had recently been discharged from wound care, as the wound had healed.

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) -76-2351
LICENSING EVALUATOR NAME: Sabel Martinez	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

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-20230322131219

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: CANYON VILLAS	FACILITY NUMBER: 372004738
	VISIT DATE: 08/29/2023

NARRATIVE

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It was alleged staff did not ensure an incontinent resident was kept clean. It was reported a source had witnessed R1 to have stool around the groin area after staff had assisted R1 with incontinence care. Interviews with staff, residents and external sources, including R1, revealed staff assisted the residents with incontinence care and there were no concerns with residents being left uncleaned.

It was alleged staff did not give a resident medication as directed by the physician. It was reported to the Department a source witnessed staff had not provided R1 a prescribed medication. On one occasion this source witnessed a medication pack indicating R1 was only provided two doses out of a thirty-dose supply.
Interview with staff, residents and external sources did not reveal any concerns regarding lack of assistance with medication management. R1 corroborated R1’s medication was provided as indicated. Staff confirmed there was one occasion where R1’s medication had arrived, but the facility had not received a physician’s order. The order was requested, and medication assistance was resumed for the medication. On a separate occasion, an outside agency nurse requested a probiotic be administered until the cycle was completed, although, the order indicated only while the resident was on antibiotics.

An interview with the agency’s supervisor corroborated the facility requested the correct order to be provided. Order was provided and medication was resumed. This supervisor met with facility management and R1, who revealed no concerns regarding lack of medication management, nor assistance.

Based on the evidence gathered throughout the investigation, there was not a preponderance of evidence to prove the alleged violations occurred, therefore, the allegations were Unsubstantiated.

An exit interview was conducted with Boller, to whom a copy of this report, and Licensee/Appeals Rights (LIC 9058) were provided.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) -76-2351
LICENSING EVALUATOR NAME: Sabel Martinez	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

LIC9099 (FAS) - (06/04)

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