374600661-9-25-2023-08-AS-SJAB-CW4MK9-20230928094023

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374600661
Report Date: 09/24/2023
Date Signed: 09/25/2023 02:27:23 AM

Substantiated

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
05/30/2023 and conducted by Evaluator Debbie Correia

COMPLAINT CONTROL NUMBER: 08-AS-20230530155521

FACILITY NAME:	CALIFORNIA HOME FOR SENIORS		FACILITY NUMBER:	374600661
ADMINISTRATOR:	GLORIA S. QUILLOPE		FACILITY TYPE:	740
ADDRESS:	1061 E. BRADLEY AVENUE		TELEPHONE:	(619) 448-2870
CITY:	EL CAJON	STATE: CA	ZIP CODE:	92021
CAPACITY:	15	CENSUS: 14	DATE:	09/24/2023
		UNANNOUNCED	TIME BEGAN:	04:30 PM
MET WITH:	Caregiver Salvacion Managuit		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Illegal eviction.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced visit to deliver investigative findings on the above-listed complaint allegation. LPA Correia met with Caregiver Salvacion Managuit to whom was explained the purpose for the visit.

The Department’s investigation consisted of staff and outside source interviews as well as facility, resident, and outside source records reviews.

It was alleged that facility Staff 1 (S1) illegally evicted Resident1 (R1) from the facility. R1 was admitted to the facility on March 10,2023, at the time of admission a review of outside source records dated, March 10, 2023, revealed R1 had a diagnosis including but not limited to Dementia, Psychotic Disturbance, Anxiety, and Depression, and a history of UTIs. A review of R1’s facility records revealed on April 13, 2023, R1 was sent to the hospital for displaying aggressive and violent behavior, having a history of UTIs, and S1 felt R1 needed a psychiatric evaluation. As noted above, these behaviors were clearly documented at the time of R1’s admission. A facility file review revealed no documentation of incident reports regarding R1’s changes in condition, nor an eviction notice.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie Correia	TELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2023

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-20230530155521

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: CALIFORNIA HOME FOR SENIORS	FACILITY NUMBER: 374600661
	VISIT DATE: 09/24/2023

NARRATIVE

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Several outside source interviews revealed R1’s Responsible Parties (RP1 and RP2) were notified by S1 that R1 needed a higher level of care and would not be allowed to return to the facility upon release from the hospital. In contrast, interviews with facility staff revealed RP2 had chosen to relocate R1. An additional outside source interview and records review revealed RP2 agreed R1 needed to be relocated, after being notified that R1 was not able to return to the facility, and RP1 was notified by S1 that they needed to retrieve R1’s belongings to not accrue additional fees.

On August 24, 2023, Community Care Licensing (CCL) received documentation of the series of events that occurred since R1 was admitted to the facility, which is a memory care facility, to negate the allegation, however a review of the documentation provided constituted that a notice of eviction should have been served to notify all parties, and to allow CCL to implement mandated procedures to determine if the reasons for the eviction/relocation was valid.

Based on interviews and records reviews the above listed allegation was determined to be substantiated as there is a preponderance of evidence to show that the violation occurred. Pursuant to the California Code of Regulations, Title 22, Division 6, deficiency is being cited on the attached LIC 9099 D.

An exit interview was conducted with Caregiver Managuit and a copy of this report and Licensee/Appeal Rights (LIC 9058) were provided to Caregiver Managuit at the conclusion of the visit. Signature below confirms receipt of the reports.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie Correia	TELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2023

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20230530155521

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: CALIFORNIA HOME FOR SENIORS	FACILITY NUMBER: 374600661
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/24/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type B 10/27/2023 Section Cited CCR 87224(a)	1 2 3 4 5 6 7	(a) The licensee may evict a resident for one or more of the reasons...(4) if, after admission, ...the resident has a need not previously identified and a reappraisal has been conducted... pursuant to Section 87463. This requirement was not met based on:	1 2 3 4 5 6 7	Per phone call with Licensee Quillope and meeting with Caregiver Managuit, a CCL approved vendor will come to conduct training on eviction procedures with facility management staff. Licensee to provide proof of training by POC due date.
	8 9 10 11 12 13 14	Based on interviews and record reviews, Resident 1 (R1) was not allowed back to the facility after release from the hospital, and the Licensee did not follow proper procedures per Title 22. This posed a potential rights violation to 1 out of 12 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: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie Correia	TELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2023

LIC9099 (FAS) - (06/04)

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