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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374600949
Report Date: 03/29/2024
Date Signed: 03/29/2024 03:51:42 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,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/02/2020 and conducted by Evaluator Sabel Martinez
COMPLAINT CONTROL NUMBER: 08-AS-20201202152956
FACILITY NAME:ANNE'S PLACE IIFACILITY NUMBER:
374600949
ADMINISTRATOR:ANNA OSBORNEFACILITY TYPE:
740
ADDRESS:2690 MARY LANE PLACETELEPHONE:
(760) 522-1989
CITY:ESCONDIDOSTATE: CAZIP CODE:
92025
CAPACITY:6CENSUS: 5DATE:
03/29/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:House Manager Dearme DoverteTIME COMPLETED:
04:10 PM
ALLEGATION(S):
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Licensee is resident #1's payee
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced complaint investigation visit to deliver findings. The LPA introduced himself and disclosed the purpose of the visit to Caregiver Alexandra Leon. House Manager Dearme Doverte and Licensee Ana Osborne arrived during the visit and assisted the LPA.

Throughout the investigation, the Department secured pertinent records and conducted interviews with external and internal sources, including staff and clients.

It was alleged the Licensee was the assigned payee for a resident. On 12/02/2020, it was reported to the Department that the Licensee was assigned to be Resident #1’s (R1) payee. Review of records along with multiple interviews, including the Licensee, confirmed the Licensee was R1’s payee. The records did not reveal any written documented consent from R1, nor R1’s guardian. It was also revealed R1’s guardian was actively working with the Licensee to re-assign R1’s guardian as the payee for social security benefits. (See LIC 9099C for continuation of report.)
Substantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 380-3797
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 755-7595
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 08-AS-20201202152956
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: ANNE'S PLACE II
FACILITY NUMBER: 374600949
VISIT DATE: 03/29/2024
NARRATIVE
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Based on evidence obtained, the allegation was Substantiated. The deficiency was cited in accordance with California Code of Regulations, Title 22, and listed on the LIC 9099D. A plan of correction was jointly formulated with Licensee Odborne.

An exit interview was conducted with Doverte and Osborne, to whom a copy of this report, LIC 9099D, and Licensee/Appeals Rights (LIC 9058), were provided.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 380-3797
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 755-7595
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 08-AS-20201202152956
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: ANNE'S PLACE II
FACILITY NUMBER: 374600949
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/28/2024
Section Cited
CCR
87468.2(a)(26)(B)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:(26)To manage their financial affairs. A licensee shall not require residents to deposit their personal funds with the licensee. Except as provided for in approved continuing care agreements, a licensee, or a spouse, domestic partner, relative, or employee of a licensee, shall not do any of the following: (B) Become or act as a representative payee for any payments made to a resident, without the written and documented consent of the resident or the resident’s representative. This requirement was not met as evidenced by:
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Licensee agreed to review personal rights regulations. Resident is no longer residing at the facility, therefore, the Plan of Correction was cleared on today's date.
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Based on review of records and interviews, the licensee did not ensure the Licensee had prior written consent to be assigned as R1's payee, which posed a potential health, safety, and personal rights risk to 1 of 5 residents 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: Simon JacobTELEPHONE: (619) 380-3797
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 755-7595
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/02/2020 and conducted by Evaluator Sabel Martinez
COMPLAINT CONTROL NUMBER: 08-AS-20201202152956

FACILITY NAME:ANNE'S PLACE IIFACILITY NUMBER:
374600949
ADMINISTRATOR:ANNA OSBORNEFACILITY TYPE:
740
ADDRESS:2690 MARY LANE PLACETELEPHONE:
(760) 522-1989
CITY:ESCONDIDOSTATE: CAZIP CODE:
92025
CAPACITY:6CENSUS: 5DATE:
03/29/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:House Manager Dearme DoverteTIME COMPLETED:
04:10 PM
ALLEGATION(S):
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Licensee not meeting the resident's needs
Licensee violated the resident's personal rights
Licensee not maintaining accurate records keeping of the administration of medication
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced follow up complaint investigation visit, and delivered complaint findings. The LPA introduced himself and disclosed the purpose of the visit to Caregiver Alexandra Leon. House Manager Dearme Doverte and Licensee Ana Osborne arrived during the visit and assisted the LPA.

Throughout the investigation, the Department secured pertinent records and conducted interviews with external and internal sources, including staff and residents.

It was alleged the Licensee did not meet a resident's needs. It was reported to the Department a resident had a diabetic diet in place and the facility was not meeting this diet. Interview with internal and external sources did not reveal any concerns regarding the food that was provided at the facility. An interview with the resident in question, and their Responsible Party, did not reveal any concerns with the food that was provided to said resident. The resident stated the resident’s dietary needs were being met. A review of the resident’s records, including a physician’s report, revealed the resident had a renal diet and sugary foods should be avoided.
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 380-3797
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 755-7595
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 08-AS-20201202152956
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: ANNE'S PLACE II
FACILITY NUMBER: 374600949
VISIT DATE: 03/29/2024
NARRATIVE
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The investigation did not yield enough evidence to prove the facility staff were not following this diet.

It was alleged the Licensee violated a resident's personal rights. It was reported to the Department a resident was not allowed to have private telephone conversations and that the resident was not allowed to seek a new facility. Interviews with internal and external sources revealed conflicting statements regarding the resident’s desire to leave the facility, and the resident’s conservatorship status. An interview with the resident did not reveal any concerns with the facility not allowing the resident to relocate, nor the facility not allowing the resident to have private phone conversations. Interviews with the resident’s responsible party and the facility administrator revealed there had been concerns regarding a third party contacting the resident, encouraging the resident to relocate. Records obtained by the Department confirmed the resident had a guardian appointed prior to the resident being admitted.

It was alleged the Licensee did not maintain accurate record keeping of the administration of medication. It was reported to the Department the facility did not document the administration of insulin for a resident. Interviews with a source revealed the resident in question was diabetic but was not prescribed insulin. Review of records, including medication records, and interviews of sources did not reveal any concerns regarding lack of documentation. Additionally, interviews along with the resident’s physician’s report revealed the resident had a history of refusing medication.

An exit interview was conducted with Doverte and Osborne, to whom a copy of this report, and Licensee/Appeals Rights (LIC 9058), were provided.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 380-3797
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 755-7595
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5