374600799-1-30-2023-08-AS-LTEZ-CNLV8B-20230131151228

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374600799
Report Date: 01/30/2023
Date Signed: 01/30/2023 12:18:04 PM

Unsubstantiated

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
05/19/2020 and conducted by Evaluator John Rante

PUBLIC

COMPLAINT CONTROL NUMBER: 08-AS-20200519172332

FACILITY NAME:	CARLSBAD BY THE SEA		FACILITY NUMBER:	374600799
ADMINISTRATOR:	JOAN E. JOHNSON		FACILITY TYPE:	741
ADDRESS:	2855 CARLSBAD BLVD.		TELEPHONE:	(760) 729-2377
CITY:	CARLSBAD	STATE: CA	ZIP CODE:	92008
CAPACITY:	224	CENSUS: 190	DATE:	01/30/2023
		UNANNOUNCED	TIME BEGAN:	11:41 AM
MET WITH:	Executive Director Paula Digerness		TIME COMPLETED:	12:20 PM

ALLEGATION(S):

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- Lack of care and supervision resulted in injuries to resident
- Licensee did not report an incident as required

INVESTIGATION FINDINGS:

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Licensing Program Manager (LPM) John Rante conducted an unannounced Complaint Visit. LPM met with Executive Director Paula Digerness, and discussed the purpose of the visit. Today’s visit is to deliver findings for the above allegations.

It was alleged lack of care and supervision resulted in Resident 1 sustaining injuries of unknown origin from March, 2020, to May, 2020.

Review of Facility Records from September, 2019, identify R1 as needing additional time due to transfers and first aid treatment to skin tears. R1 is identified as a 1-person assist with transfers, and notes they required additional time due to transfers and first aid treatment to skin tears. In addition, R1’s physical functioning status indicates the use of a wheelchair/motorized scooter for mobility. In addition, staff assist with incontinence issues every two (2) hours or as needed.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Icela Estrada	TELEPHONE: (619) 688-6866
LICENSING EVALUATOR NAME: John Rante	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2023

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-20200519172332

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: CARLSBAD BY THE SEA	FACILITY NUMBER: 374600799
	VISIT DATE: 01/30/2023

NARRATIVE

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(Continue...1)

R1’s PCP identifies R1 does not have a history of skin breakdown, does not require continuous bed care, and does not have a motor impairment. Assistance is needed with bathing, dressing/grooming, and toileting. In addition, R1 is now noted as a “nearby assist,” regarding transferring. Facility records then show on March 22, 2020, staff observed R1 sustained a skin tear to their lower leg. It is noted R1 was unable to recall when or how it they sustained the injury.

In their interview, R1 acknowledged receiving assistance with Activities with Daily Living (ADL) from facility staff, and indicated the facility’s signal system is utilized when assistance is needed. R1 was unable to describe the incident on March 22, 2020, as it occurred. In addition, R1 was observed with no apparent injuries. Their room was clean and kempt, with no obstructions in the walkways.

Interviews with staff acknowledge R1 does call for assistance during the evening hours. Staff interviews also indicate the resident will, at times, attempt to get out of bed. When assistance is requested in the evening, staff indicated it is to assist the resident with toileting. Staff acknowledged conducting rounds on the residents, including R1, once every two (2) or three (3) hours. Staff 1 (S1) was identified as the individual who responded to R1 on March 22, 2020. S1 was unable to recall the incident, but indicated what was documented, is what S1 observed; which was R1 was observed with an injury while being assisted with toileting. The injury was cleaned and dressed, and the PCP and responsible party was notified.

Based on interviews conducted and pertinent records reviewed, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove the alleged violation occurred.

It was also alleged the facility is not reporting incidents as required. The incident that occurred on March 22, 2020, notes R1’s PCP, as well as their responsible party, were notified on March 22, 2020, and March 23, 2020, respectively. Per Regional Office File Review, LPM was unable to locate any other reportable incidents from March, 2020, to May, 2020.

SUPERVISOR'S NAME: Icela Estrada	TELEPHONE: (619) 688-6866
LICENSING EVALUATOR NAME: John Rante	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2023

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20200519172332

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: CARLSBAD BY THE SEA	FACILITY NUMBER: 374600799
	VISIT DATE: 01/30/2023

NARRATIVE

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(Continue...2)

Interviews with staff indicate that if a reportable incident occurs for a resident during the evening shift, responsible parties and PCPs are notified during the AM Shift. The incident that occurred on March 22, 2020, is noted to be reported to R1’s PCP by S1, and R1’s responsible party is noted to be notified by Staff (S2).

Interviews with outside sources indicate not being notified timely of incidents for the resident, as they occur. Interviews with R1’s PCP Office, confirmed being notified by the facility, and the residents responsible party, of the incident on March 22, 2020.

Based on interviews conducted and pertinent records reviewed, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove the alleged violation occurred. The allegations are determined to be unsubstantiated.

The Licensee was provided a copy of their appeal rights (LIC9058 03/22), and their authorized representative’s signature on this form, acknowledges receipt of these rights. An exit interview was conducted, and a copy of this report, along with the appeal rights, was given to Paula Digerness and the conclusion of the visit.

SUPERVISOR'S NAME: Icela Estrada	TELEPHONE: (619) 688-6866
LICENSING EVALUATOR NAME: John Rante	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2023

LIC9099 (FAS) - (06/04)

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