374600378-12-15-2023-08-AS-JLOT-CZZU6A-20240131141800

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374600378
Report Date: 12/14/2023
Date Signed: 12/15/2023 10:15:06 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/18/2020 and conducted by Evaluator Mark Mandel

COMPLAINT CONTROL NUMBER: 08-AS-20200818154152

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: 150	DATE:	12/14/2023
		UNANNOUNCED	TIME BEGAN:	02:21 PM
MET WITH:	Administrator -Tania Dupre		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Facility staff did not follow resident's care agreement.

Facility staff did not follow physician's orders.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Mark Mandel conducted an unannounced visit to follow-up on a complaint investigation regarding the above-mentioned allegations. LPA identified himself and was granted entry by and met with Administrator, Tania Dupre. LPA stated the purpose of the visit and discussed the elements of the complaint with Administrtor, Tania Dupre. LPA delivered the investigative findings to Ms. Dupre .
On 08/18/2020, the Department received a complaint alleging that facility staff did not follow Resident 1's (R1) (see LIC 811 Confidential Names List) care agreement and did not follow R1's physician's orders. The Department’s investigation consisted of a facility visit, staff interview and records review.

(Cont. on LIC9099-C)

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Mark Mandel	TELEPHONE: (619) 990-1407
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

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-20200818154152

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: CYPRESS COURT ESCONDIDO	FACILITY NUMBER: 374600378
	VISIT DATE: 12/14/2023

NARRATIVE

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(Cont. from LIC 9099)

It was alleged that the facility staff did not follow R1's care agreement on 08/17/20 by taking her to the emergency room before contacting the Power of Attorney for R1. Staff 1 (S1) stated that a new property manager took over the facility and moved records prior to 2021 off site, which would include resident care records pertaining to the alleged incident that occurred on 08/17/20. In accordance with Title 22 regulations, facilities are are only required to keep facility records for three years. No additional records or other relevant information from outside sources was provided to support this allegation.

It was also alleged that the facility staff did not follow R1's physician's orders by continuing to administer a prescribed medication, Donepezil, to R1 from, on or about, 05/20/2019, until, on or about, 11/21/2019. S1 stated that a new property manager took over the facility and moved records prior to 2021 off site, which would include medication administration records pertaining to the allegation. In accordance with Title 22 regulations, facilities are only required to keep facility records for three years. No additional records or other relevant information from outside sources was provided to support this allegation.

Based on the evidence reviewed, the allegations that facility staff did not follow R1's care agreement and did not follow R1's physician's orders are Unsubstantiated, as the preponderance of evidence standard was not met. An exit interview was conducted with Administrator, Tania Dupre, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 03/22).

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Mark Mandel	TELEPHONE: (619) 990-1407
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

LIC9099 (FAS) - (06/04)

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