374600950-4-12-2023-08-AS-SJAB-CR3RD5-20230420125518

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374600950
Report Date: 04/12/2023
Date Signed: 04/12/2023 01:22:24 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
08/15/2022 and conducted by Evaluator Esther Miller

PUBLIC

COMPLAINT CONTROL NUMBER: 08-AS-20220815162822

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: 53	DATE:	04/12/2023
		UNANNOUNCED	TIME BEGAN:	10:52 AM
MET WITH:	Susan Sorensen, Administrator		TIME COMPLETED:	12:23 PM

ALLEGATION(S):

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Facility did not safeguard personal property.
Facility did not protect resident from emotional abuse.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Esther Miller conducted an unannounced complaint investigation visit to the facility in order to deliver findings on the above allegation. LPA was granted entry to the facility by Susan Sorensen, Administrator, after identifying herself and explaining the reason for the visit.

On August 15, 2022, it was alleged that facility did not safeguard personal property and facility did not protect resident from emotional abuse. The Department’s investigation consisted of review of facility and outside source records, and interviews of facility staff and outside sources.

Staff and outside source interviews indicated that Resident 1 (R1) and Resident 2 (R2) were roommates from February 2022 to until August 2022. During that time, facility records revealed that both residents did not get along and accused each other of taking items. Interview with an outside source

[Continued on LIC9099-C, Page 1 of 2]

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther Miller	TELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023

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-20220815162822

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: 04/12/2023

NARRATIVE

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indicated that R1 frequently misplaced items and found the same items later. Facility documented a conversation with R1 where they stated that all items that had been thought stolen were found in R1’s room by R1. R1 wrote various letters to administrative staff admitting that stolen items had been found in obscure places in their room. Interviews with staff and facility records revealed that R1 had a closet that could only be opened with a key that only R1 possess. Items claimed by R1 to have been stolen had been found inside the closet by staff after R1 directed that they look there. Administrator had reviewed cameras positioned in the hallways to verify that no one had entered R1’s room when an item was reported stolen by R1. Administrator stated that the cameras reveled that no one had entered R1’ room during the period of time R1 claimed items were stolen from them. LPA could not reach R1 for an interview.

It was also alleged that facility did not protect resident from emotional abuse, specifically R1 from R2. Facility documents revealed multiple letters that R1 sent administrative staff regarding their dissatisfaction with their living arrangement with R2. The letters stated that R1 was being verbally abused by R2 and caused medical symptoms to worsen. Facility documented that they offered either R1 or R2 to move out of the room twice in June 2022, but neither wanted to. R2 did agree to move out on August 23, 2022. On September 21, 2022, R1 wrote that they did not feel safe around R2 and wanted R2 to be moved out of the facility. The letters went as far as stating that R1 was “asking [R1’s] Pastor to find a lawyer that does abuse cases.” Facility documented a conversation held with R1 on September 21, 2022. R1 told staff that they felt R2 was verbally abusive when R2 would say “What’s wrong with you?” because it reminded R1 of their abusive parents. Long Term Care Ombudsman did not indicate they received any reports of abuse after visiting R1 at the facility in November of 2022. LPA could not reach R1 or R2 for an interview.

Based on the evidence obtained during the complaint investigation, the allegation that facility did not safeguard personal property and facility did not protect resident from emotional abuse is found to be UNSUBSTANTIATED, meaning that although the allegation may have happened or may be valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Administrative; a copy of this report and Licensee's Rights (LIC9058) were provided to Administrator.

[Continued from LIC9099, Page 2 of 2]

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther Miller	TELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023

LIC9099 (FAS) - (06/04)

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