374600378-5-3-2021-08-AS-IESA-C3KAM8-20210601002019

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374600378
Report Date: 05/03/2021
Date Signed: 05/03/2021 03:20:59 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
07/20/2020 and conducted by Evaluator Adam Hamer

COMPLAINT CONTROL NUMBER: 08-AS-20200720150832

FACILITY NAME:	CYPRESS COURT ESCONDIDO		FACILITY NUMBER:	374600378
ADMINISTRATOR:	DANIEL-HERR, DONNA		FACILITY TYPE:	740
ADDRESS:	1255 N. BROADWAY		TELEPHONE:	(760) 747-1940
CITY:	ESCONDIDO	STATE: CA	ZIP CODE:	92026
CAPACITY:	293	CENSUS: 122	DATE:	05/03/2021
		UNANNOUNCED	TIME BEGAN:	02:35 PM
MET WITH:	Alisa Chavarria, Assisted Living Director		TIME COMPLETED:	02:54 PM

ALLEGATION(S):

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Staff financially abused resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Adam Hamer conducted an unannounced complaint investigation tele-visit on today’s date via FaceTime due to COVID-19. LPA identified himself, spoke with Assisted Living Director Alisa Chavarria and discussed the purpose of the visit, which was to deliver the finding for the above allegation.

The Department’s investigation included interviews with staff, the administrator and outside sources. Facility and outside source records were also obtained by the Department and reviewed for pertinent evidence.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Adam Hamer	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2021

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 4

Control Number 08-AS-20200720150832

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: CYPRESS COURT ESCONDIDO	FACILITY NUMBER: 374600378
	VISIT DATE: 05/03/2021

NARRATIVE

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The Department received a complaint on July 20, 2020 alleging that the staff financially abused resident (R1) (See LIC 811 Confidential Names List). Interviews with staff, outside sources and a records review revealed that, on June 15, 2020, staff (S1) (see LIC 811 Confidential Names List) was a caregiver working at the facility. That day, S1 had an opportunity to be alone in R1’s room, at which time S1 took R1’s property, a personal check that was in their room. On June 16, 2020, S1 attempted to cash R1’s check at a check cashing store, with S1’s name written on the check as the payee and endorsed with R1’s purported signature. Per law enforcement evidence, R1 did not, in fact, write or authorize the check that S1 attempted to cash.

An outside source reported the incident to the police and an investigation was conducted by the police. The investigation included showing witnesses surveillance photos of S1 trying to cash the check, and verifying that R1 never gave permission to S1 to take the check, complete it and sign R1’s name on the signature line. An arrest warrant was subsequently issued for S1’s arrest for three (3) felony charges including identity theft, forgery and financial elder abuse by a caretaker. Further investigation revealed that R1’s wallet, containing a bank card and identification, was also missing from R’1s room at the facility. S1 was terminated from employment at the facility on June 16, 2020.

The Department’s interviews with staff, outside sources and records review also revealed that, prior to the theft incident on June 15, 2020, S1 had worked at the facility for almost two (2) weeks. Prior to S1’s employment at the facility, only one reference check was conducted which revealed that S1 had not worked at the facility that S1 had used as a reference. Hiring S1 to work at the facility without proper vetting and giving them an opportunity to be alone in R1’s room created an unreasonable risk to the residents in care. Although the facility provided R1 with a secure lockbox in their bedroom closet and a lockable cabinet in their bathroom, the check was kept in a box in the bedroom along with R1’s files and other documents.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Adam Hamer	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2021

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20200720150832

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: CYPRESS COURT ESCONDIDO	FACILITY NUMBER: 374600378
	VISIT DATE: 05/03/2021

NARRATIVE

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Based on the evidence obtained during the complaint investigation, the allegation that staff financially abused resident is found to be SUBSTANTIATED, as there is a preponderance of the evidence to prove that the allegation occurred. A citation is being issued in accordance with California Code of Regulations, Title 22, and is listed on the LIC9099D, and a plan of correction was developed with Ms. Chavarria.

An exit interview was conducted via FaceTime with Ms. Chavarria, and a copy of this report, including the LIC 9099D, the LIC 811 and Applicant/Licensee Rights (LIC 9058 01/16) were emailed to the email address she provided to LPA; an email read receipt confirms receipt of these documents.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Adam Hamer	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 08-AS-20200720150832

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: CYPRESS COURT ESCONDIDO	FACILITY NUMBER: 374600378
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/03/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/28/2021 Section Cited CCR 87468.2(a)(8)	1 2 3 4 5 6 7	87468.2. Additional Personal Rights of Residents in Privately Operated Facilities. (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated	1 2 3 4 5 6 7	The Administrator will conduct a staff training with HR staff on following the Plan of Operation and properly vetting staff before hiring, and provide proof of correction by the POC date.
	8 9 10 11 12 13 14	residential care facilities for the elderly shall have all of the following personal rights: (8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. Based on interviews and records review, staff #1 financially exploited R1 which posed a potential personal rights risk to 1 out of 150 residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	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: Denise Powell	TELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Adam Hamer	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2021

LIC9099 (FAS) - (06/04)

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