374600372-6-28-2021-08-AS-DPOL-C4H39X-20210630180351

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374600372
Report Date: 06/28/2021
Date Signed: 06/28/2021 04:01:46 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
02/04/2020 and conducted by Evaluator Elizabeth Hamilton

COMPLAINT CONTROL NUMBER: 08-AS-20200204085131

FACILITY NAME:	CLOISTERS OF THE VALLEY, LLC		FACILITY NUMBER:	374600372
ADMINISTRATOR:	CHANNA KELLY		FACILITY TYPE:	740
ADDRESS:	4171 CAMINO DEL RIO SOUTH		TELEPHONE:	(619) 283-2226
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92108
CAPACITY:	0	CENSUS: 0	DATE:	06/28/2021
		UNANNOUNCED	TIME BEGAN:	03:18 PM
MET WITH:	Licensee, Carol Van Forst		TIME COMPLETED:	03:32 PM

ALLEGATION(S):

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Staff not administering medications as prescribed
Staff not treating residents with dignity and respect
Staff is limiting between-meal nourishment
Staff not providing assistance with incontinence care
Staff not assisting with ambulation
Staff not assisting resident with dressing
Staff are asking resident to purchase personal items for staff
Facility skilled professional is not assisting resident with diabetic testing

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Elizabeth Hamilton conducted an unannounced complaint investigation telephone visit due to the facility being closed. LPA identified herself and discussed the purpose of the visit, which was to deliver findings for the above allegations with Licensee, Carol Van Forst.

The Department’s investigation consisted of records reviewed, interviews with staff, residents and outside sources.

It was alleged that between January 2020 and February 2020 staff did not administer Resident 1’s (R1 – See LIC 811 Confidential Names List) medication as prescribed. Interview with staff revealed that although R1 was able to administer their own medication R1 would refuse to take their prescribed medications. Records reviewed revealed that R1 was able to manage their own medications; however, it was notated that refrigeration was needed to store medications. Medication Administration Record (MAR) revealed R1 refused medications on multiple occasions.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Elizabeth Hamilton	TELEPHONE: (619) 929-7590
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021

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-20200204085131

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: CLOISTERS OF THE VALLEY, LLC	FACILITY NUMBER: 374600372
	VISIT DATE: 06/28/2021

NARRATIVE

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It was alleged that between January 2020 and February 2020 staff did not treat residents with dignity and/or respect. Interviews with staff and outside sources revealed no witnessed incidents or reported incidents of staff not treating residents with dignity and/or respect. Interviews with residents did not indicate any resident witnessed or were subject to not being afforded dignity and/or respect.

It was alleged that between January 2020 and February 2020 staff were limiting between-meal nourishment for R1. Interviews with staff and other residents revealed that residents were provided three meals a day and snacks in between meals. Interviews with other residents revealed those who were on a special diet were given other options to choose from based on their likes and their prescribed diets.

It was alleged that between January 2020 and February 2020 staff did not provide R2 assistance with incontinence care. Interviews with staff revealed residents were able to request assistance by calling staff from the residents’ call light located in the residents’ room by their bed and their couch. Residents were also checked on every two hours even when assistance with incontinence care was not requested. Interviews with outside sources revealed that during their visits R2 was always dry and there was no indication their incontinence wasn’t cared for. Another outside source for an unrelated resident confirmed incontinence care was provided by the facility appropriately.

It was alleged that between January 2020 and February 2020 staff did not assist R2 with ambulation. Interviews with staff revealed that if residents needed assistance, residents would call for assistance through their call light located in their room next to their bed and their couch. Residents who received incontinent care were checked on every two hours including R2. Interviews with outside sources revealed R2 would never try and go to the bathroom by themselves as their legs were too weak. However, there was no concern of staff not assisting with ambulation.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Elizabeth Hamilton	TELEPHONE: (619) 929-7590
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20200204085131

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: CLOISTERS OF THE VALLEY, LLC	FACILITY NUMBER: 374600372
	VISIT DATE: 06/28/2021

NARRATIVE

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It was alleged that between January 2020 and February 2020 staff did not assist R2 with dressing. Interviews with staff revealed that many residents did not have many pieces of clothing and their laundry was done daily so they would have clean clothing to wear. Interviews with outside sources revealed that R2 did not have much clothing so they could not confirm if R2’s clothing was from the day prior. However, they were able to confirm R2 had clean clothing every time they visited.

It was alleged that between January 2020 and February 2020 Staff 1 (S1) asked R1 to purchase personal items for S1. During the investigation S1 denied requesting any resident to purchase personal items. Interview with Executive Director revealed that R1 purchased a burrito for a Caregiver; however, they did not request or accept the item and reported it to their Supervisor. Interviews with other staff revealed there were no known requests or purchases made for staff members and that residents buying items for staff was not allowed. Interviews with other residents revealed they were not asked to purchase personal items for staff by staff and there were no known incidents of any other residents purchasing items for staff.

It was alleged that between January 2020 and February 2020 a facility skilled professional was not assisting R1 with diabetes testing. Records reviewed revealed that R1 did not need assistance with diabetes testing; however, did need assistance with refrigeration. MAR revealed R1 was prescribed the Novolog Flex Pen and would self-test. MAR further revealed multiple refusals from R1 as well as multiple instances R1 was not at the facility to test.

The Department has investigated the allegations listed above. Based on evidence obtained, including interviews and records reviewed the above allegations are unsubstantiated as the Department could not meet the preponderance of the evidence standard.

An exit interview was conducted with Licensee and a copy of this report, confidential names list and Licensee/Appeals Rights (LIC 9058 01/16) was provided to the Licensee via email. An electronic receipt of confirmation was requested to be sent by the Licensee upon receipt of the documents.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Elizabeth Hamilton	TELEPHONE: (619) 929-7590
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021

LIC9099 (FAS) - (06/04)

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