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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600688
Report Date: 05/08/2024
Date Signed: 05/08/2024 12:06:28 PM


Document Has Been Signed on 05/08/2024 12:06 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:FAMILY-STYLE CARE IIFACILITY NUMBER:
374600688
ADMINISTRATOR:JOSEFINA HULSEYFACILITY TYPE:
740
ADDRESS:2847 MORNINGSIDE STREETTELEPHONE:
(619) 856-4968
CITY:SAN DIEGOSTATE: CAZIP CODE:
92139
CAPACITY:0CENSUS: 0DATE:
05/08/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:N/A. Report Certified Mailed to Licensee.TIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted a Case Management process to investigate the circumstances leading up to the death of a resident who lived at facility. Since the facility closed on 05/04/2023 due to a change in ownership, this report and its finding was delivered to Licensee via USPS certified mail.

On 03/10/2022, Licensee submitted a written LIC624 Incident Report to CCLD describing Resident #1 (R1) falling at the facility on 03/02/2022, and then being sent to a hospital emergency room on 03/03/2022. Then on 03/21/2022, Licensee submitted an LIC624 to CCLD to report that R1 subsequently returned to the facility, declined in health while under hospice care, and then passed away on 03/17/2022.

According to R1’s LIC602 Physician’s Report (dated 11/16/2014), which was operative during the complaint timeframe, R1’s doctor noted that R1 had generalized weakness and Mild Cognitive Impairment (MCI), but also deemed that R1 was “ambulatory.” According to R1’s LIC603 care appraisal (dated 05/28/2018), which was operative during the complaint timeframe, Licensee had assessed R1 and determined they were able to “move around the facility independently with walker.” Staff interviews corroborated that R1 was able to walk independently with a walker leading up to their fall.

Staff interviews aligned to show: Around 6:00 PM on 03/02/2022, R1 was ambulating with their walker device inside a facility common area. Staff #1 (S1) was in the adjacent kitchen and had earlier seen R1 sitting on the living room couch. When S1 heard R1 yell out, they quickly responded to find R1 on the floor. The spot where R1 fell was near the junction of the facility’s living room and an adjoining hallway area. Later, R1 was sent via 911 to a local hospital emergency room, where X-rays showed they had new “closed left hip fracture,” “C2 cervical fracture,” and “odontoid fracture with type III morphology.” [CONTINUED ON LIC 809-C]
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: FAMILY-STYLE CARE II
FACILITY NUMBER: 374600688
VISIT DATE: 05/08/2024
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[CONTINUED FROM LIC 809]

On 03/18/2022, a CCLD investigator visited the facility to collect records, interview pertinent staff, and perform welfare checks on residents in care. They also inspected the junction area where R1 was found on the floor by staff. Their photographs showed: The transition of the carpet surface to vinyl-like surface was covered with a wooden molding/trim piece/strip (designed for this purpose). There was a section of molding/trim, approximately 6 to 8 inches long, which was broken and partially sticking up, while remaining attached to the larger strip connected to the floor. This created a potential trip hazard.

R1 was unable to be interviewed, since they had already passed away as of the date of CCLD’s investigation. All available staff interviews unanimously showed: a) The exact moment of R1’s fall was not witnessed by others; and b) After the fall, R1 was not able to tell staff exactly how or what caused them to fall. Staff interview revealed: The above section of floor molding/trim had been broken and reported to Licensee for needed repair, about one to two weeks prior to R1’s 03/02/2022 fall incident. It was repaired/replaced a few days after CCLD’s 03/18/2022 site visit.

Based on interviews and records, a preponderance of evidence exists to show that Licensee did not maintain an area of the facility in good repair. However, the available evidence is not sufficient to prove that the broken section of floor molding/trim caused R1 to trip and fall, or that it was the proximate cause for R1’s fall, injury, and/or death. One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the LIC 809-D) page. Since the facility had closed and ceased operations as of the date of deficiency issuance, no Plan of Correction was formed with the Licensee.

A copy of this report, the LIC 809-D, and the Licensee/Appeal Rights (LIC9058 03/22) were provided to Licensee via USPS certified mail.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 05/08/2024 12:06 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: FAMILY-STYLE CARE II
FACILITY NUMBER: 374600688

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/08/2024
Section Cited
CCR
87303(a)

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87303 Maintenance and Operation: “(a) The facility shall be…in good repair at all times.” This requirement was not met, as evidenced by:
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As of the date of deficiency issuance, facility had closed and ceased operations. Therefore, no Plan of Correction was formed with the Licensee.
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Based on records and interviews, Licensee did not maintain the facility in good repair at all times. This posed a potential health, safety, and personal rights risk to 5 of 5 residents [R1 through Resident #5 (R5)] in care.
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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: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2024
LIC809 (FAS) - (06/04)
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