374600378-9-24-2021-08-AS-DPOL-C7CVPV-20210930163722

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374600378
Report Date: 09/24/2021
Date Signed: 09/24/2021 03:30:38 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
10/07/2020 and conducted by Evaluator Adam Hamer

COMPLAINT CONTROL NUMBER: 08-AS-20201007141853

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:	09/24/2021
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Dennis Prejusa, Resident Care Director		TIME COMPLETED:	12:25 PM

ALLEGATION(S):

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Resident's bed was in disrepair.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Adam Hamer conducted an unannounced complaint investigation visit on today’s date. LPA arrived at the facility and was granted entry after identifiying himself and disclosing the purpose of the visit, which was to deliver the finding for the above allegation. LPA later met with Resident Care Director Dennis Prejusa to deliver the finding.

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

The Department received a complaint on October 7, 2020 that resident's bed was in disrepair. The Department’s interviews with staff revealed that a resident at the facility, resident #1(R1)(See Confidential Names List - LIC 811), had requested a new bed after complaining to their medical professional in September 2020 about their bed. Subsequently, after receiving the bed, R1 had complained that the bed was not working,

Unsubstantiated

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: 09/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2021

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-20201007141853

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: 09/24/2021

NARRATIVE

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and then facility staff immediately called an outside vendor to examine the bed. The outside vendor went into R1's room on October 7, 2021, inspected the bed, and determined that the bed was working properly but that caregivers needed to be shown how the bed functioned with a crank system. R1 was also offered the option of an upgraded, automatic, electric bed, but R1 declined this option and decided that the existing bed was acceptable. The Department also attempted to interview R1, but it was determined that they had passed away in December 2020.

The Department's review of facility records revealed that an outside source vendor went to R1's room on October 7, 2020 to check on the functionality of R1's bed. After he examined the bed, it was then determined that the bed was functioning properly and that facility staff needed to be shown how to crank it up and down. After staff was shown how the bed functioned, there were no further service records with regard to R1's bed.

Based on the evidence obtained from the complaint investigation, the allegation that resident's bed was in disrepair is found to be UNSUBSTANTIATED, meaning that there is not a preponderance of the evidence to find that the allegation is true.

An exit interview was conducted with Mr. Prejusa and a copy of this report, a List of Confidential Names (LIC 811) and Licensee/Appeal Rights (FAS 9058 - FAS 01/16) were provided to him via the email address he provided to LPA; he expressed that he would send a confirmation email to LPA upon 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: 09/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2021

LIC9099 (FAS) - (06/04)

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