374600800-2-23-2023-08-AS-LTEZ-CPH396-20230228170236

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374600800
Report Date: 02/23/2023
Date Signed: 02/23/2023 06:54:45 PM

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
02/16/2023 and conducted by Evaluator Natasha Persaud

COMPLAINT CONTROL NUMBER: 08-AS-20230216111941

FACILITY NAME:	WESLEY PALMS		FACILITY NUMBER:	374600800
ADMINISTRATOR:	GESKE, BEN		FACILITY TYPE:	740
ADDRESS:	2404 LORING STREET		TELEPHONE:	(858) 274-4110
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92109
CAPACITY:	511	CENSUS: 320	DATE:	02/23/2023
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Executive Director, Ben Geske		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Staff did not notify responsible parties of a resident's hospitalization

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Natasha Persaud conducted a complaint investigation regarding the above mentioned allegation. LPA identified herself and discussed the allegation mentioned above with Executive Director, Ben Geske and Executive Assistant, Robert Rubio.

During the investigation, the facility was briefly toured, records reviewed, and interviews conducted with staff, residents, and outside sources. It was reported staff did not notify responsible parties of resident's hospitalization. On 01/24/23, Resident #1 (R1) was transported to the hospital via 911, due to a fall at the facility. Outside source interviews revealed R1’s spouse also resides at the facility and is the Power of Attorney for R1. R1’s responsible party was not notified of R1’s hospitalization on 01/24/23. Outside source interviews confirmed R1’s responsible party was contacted for another fall that occurred on 02/06/23 but not the fall on 01/24/23. The facility has easy access to R1’s spouse/responsible party due to the spouse residing at the facility, yet the facility did not contact R1’s responsible party. The Executive Director’s (ED) interview revealed there's a notification procedure in place that requiers staff to notify the emergency contact during the shift the event occurred. In the event, the staff is unable to reach the emergecny contact/responsible party, it is the

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha Persaud	TELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023

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-20230216111941

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: WESLEY PALMS	FACILITY NUMBER: 374600800
	VISIT DATE: 02/23/2023

NARRATIVE

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responsibility of the next shift to follow up and contact the emergency contact/responsible party.
The facility staff made an attempt to contact R1's family member but did not leave a message and no further attempts were made on the following shift. In addition, Community Care Licensing did not receive Incident Reports for either incident. Title 22 Regulation outlines incidents of certain circumstances shall be reported to CCL and the resident’s responsible party. The staff failed to notify R1’s responsible party.

Based on interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 8 is being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 01/16) were provided to Executive Director, Ben Geske whose signature below confirms receipt of these rights.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha Persaud	TELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20230216111941

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: WESLEY PALMS	FACILITY NUMBER: 374600800
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/23/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/23/2023 Section Cited CCR 87211(a)(1)	1 2 3 4 5 6 7	Reporting Requirements. A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence...This report shall include the resident's name...and treatment, if any; and disposition of the case.	1 2 3 4 5 6 7	Executive Director stated they are enforcing their notification procedures for staff by having staff sign a Notification Procedure form and the supervisror will attest on the form they have trained the employee. Also, the procedure wiill be posted in the Wellness Center as a reminder to follow procedures.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not submit a written incident report or notify R1’s responsible party or CCL for (R1) one out of 320 residents in care. This posed a potential health and safety risk to residents in care.	8 9 10 11 12 13 14	ED provided copy of the new Notification Procedures form. POC corrected.
	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: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha Persaud	TELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023

LIC9099 (FAS) - (06/04)

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