374600488-10-25-2023-08-AS-SJAB-CX5VP8-20231031163620

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374600488
Report Date: 10/25/2023
Date Signed: 10/25/2023 12:15:24 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
09/28/2023 and conducted by Evaluator Ramon Serrano

COMPLAINT CONTROL NUMBER: 08-AS-20230928085817

FACILITY NAME:	CASA DE LAS CAMPANAS		FACILITY NUMBER:	374600488
ADMINISTRATOR:	KIMBERLY FINCH-DOMINY		FACILITY TYPE:	741
ADDRESS:	18655 WEST BERNARDO DRIVE		TELEPHONE:	(858) 451-9152
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92127
CAPACITY:	582	CENSUS: 458	DATE:	10/25/2023
		UNANNOUNCED	TIME BEGAN:	10:18 AM
MET WITH:	Kim Dominy		TIME COMPLETED:	12:29 PM

ALLEGATION(S):

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Neglect/Lack of Supervision resulted in resident sustaining injury

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced visit to deliver investigative findings. LPA was granted entry into the facility and met with Executive Director Kim Dominy, to whom LPA explained the purpose of the visit.

Community Care Licensing (CCL) has investigated the above listed complaint allegation. The investigation consisted of LPA observation, review of records and interviews.

It was alleged that Neglect and or Lack of Supervision resulted in resident sustaining injury. It was reported that Resident 1 (R1) (an LIC 811 Confidential Names List was provided to the facility representative to identify the resident) sustained a "suspicious" laceration on R1's upper left arm. Records review revealed the injury R1 sustained was documented on the internal staffing notes on September 8, 2023. On the same day, September 8, 2023, R1's hospice physician sent written orders for R1's skin tear injury. R1's physicians report revealed R1 develops one skin tear almost weekly and requires assistance with wound care.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Ramon Serrano	TELEPHONE: (619) 458-2583
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

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-20230928085817

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: CASA DE LAS CAMPANAS	FACILITY NUMBER: 374600488
	VISIT DATE: 10/25/2023

NARRATIVE

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LPA visited the facility on October 3, 2023 and found R1 in the common area participating in group physical fitness activities. R1 appeared well groomed with no noticeable injuries on R1's body. R1 appeared alert and did not appear in pain or distress.

Interview with outside agency revealed that on September 27, 2023 they visited R1 and they did not observe any marks, bruises, or trauma on R1's person. Outside agency stated that from their observation the staff to resident ratio in the memory care was "good." Outside agency further stated that R1's demeanor did not look like R1 had any concern. Outside agency stated that R1 looked content, more then anything.

Interview with Director of Continuing Care revealed there is a 24 hour nurse in R1's unit which is always fully staffed. Director further stated that their are camera monitors in the; director's, nurses and supervisors office which provides "extra eyes" on the unit floor. Director stated that due to the location of the skin tear on R1's arm, it was found at the end of the day when R1 was being undressed by staff. Once the injury was found by staff, hospice was immediately notified and hospice responded with Doctor's orders.

Based upon the foregoing, the above listed allegation is unsubstantiated. This finding means that the preponderance of the evidence standard has not been met and the allegation is not valid.

An exit interview was conducted with Kim Dominy. A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to Kim Dominy whose signature below verifies receipt of these rights.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Ramon Serrano	TELEPHONE: (619) 458-2583
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

LIC9099 (FAS) - (06/04)

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