374600950-9-21-2020-08-AS-IESA-BTY549-20200930193711

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374600950
Report Date: 09/21/2020
Date Signed: 09/21/2020 12:58:32 PM

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
02/06/2020 and conducted by Evaluator Anna Kennedy

COMPLAINT CONTROL NUMBER: 08-AS-20200206163010

FACILITY NAME:	GOOD SAMARITAN RETIREMENT HOME		FACILITY NUMBER:	374600950
ADMINISTRATOR:	SUSAN SORENSEN		FACILITY TYPE:	740
ADDRESS:	1515 JAMACHA WAY		TELEPHONE:	(619) 590-1515
CITY:	EL CAJON	STATE: CA	ZIP CODE:	92019
CAPACITY:	70	CENSUS:	DATE:	09/21/2020
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:			TIME COMPLETED:	01:01 PM

ALLEGATION(S):

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Questionable death

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kennedy conducted a complaint visit via a video-calling app due to COVID-19 restrictions to deliver the findings for the above allegation. LPA identified herself and stated the purpose of the video-call to Susan Sorrensen, Administrator.

The investigation included a tour of the facility, reviewing records, and conducting interviews.

The complaint alleges that the death of a resident at the facility was questionable.

The investigation revealed that Resident 1 (R1) (see LIC811 for confidential names) was a resident at the facility from March 15, 2017 until their death on December 24, 2019. R1 had multiple health concerns identified by R1’s physician including hypertension,

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Hedgecock	TELEPHONE: (619)767-2329
LICENSING EVALUATOR NAME: Anna Kennedy	TELEPHONE: (619) 997- 4108
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2020

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-20200206163010

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: GOOD SAMARITAN RETIREMENT HOME	FACILITY NUMBER: 374600950
	VISIT DATE: 09/21/2020

NARRATIVE

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diabetes, hyperlipidemia, obesity, and sleep apnea but lived mostly independently completing personal care and hygiene, and activities without assistance. The facility provided medication management for R1.

Based document reviews and interviews it was determined that on December 24, 2019, R1 did not come to the dining room for breakfast as expected. Staff checked in R1’s room and found R1 on the bathroom floor unresponsive about 8:45 AM. 911 was called and R1 was pronounced dead by the paramedics at 9:27 AM.

Per law enforcement report dated December 24, 2019, the death did not appear to be from foul play or neglect. The coroner’s report stated R1 died of natural causes. The death report for R1, dated January 8, 2020, noted the primary cause of death was cardiac arrest.

This agency has investigated the complaint alleging R1’s death was questionable. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

An exit interview was conducted with Susan Sorensen, Administrator. via video-call. A copy of this report along with Licensee Rights (LIC9058 01/2016) was provided to Ms. Sorensen via email. An electronic response confirms the documents were received.

SUPERVISOR'S NAME: Rebecca Hedgecock	TELEPHONE: (619)767-2329
LICENSING EVALUATOR NAME: Anna Kennedy	TELEPHONE: (619) 997- 4108
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2020

LIC9099 (FAS) - (06/04)

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