374600950-9-12-2023-08-AS-SJAB-CVZPAE-20230925110835

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374600950
Report Date: 09/11/2023
Date Signed: 09/12/2023 08:11:33 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
09/05/2023 and conducted by Evaluator Iby Strong

COMPLAINT CONTROL NUMBER: 08-AS-20230905103745

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: 61	DATE:	09/11/2023
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Director Susan Sorensen		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility staff did not treat residents with dignity

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to open a complaint investigation on the above allegation. LPA identified herself and discussed the purpose of the visit with Director Susan Sorensen.

On September 5, 2023 Community Care Licensing (CCL) received a complaint stating staff did not treat multiple residents with dignity. During investigation, LPA Strong collected pertinent resident records as well as facility documentation and conducted interviews.

According to allegation, staff interactions with residents have been unkind and staff yell at residents. Interviews with multiple residents revealed no instances of staff members being rude with residents or staff raising their voice towards them. Interview with Director revealed there have been no recent reports made from family members or employees of staff being unkind or loud towards residents. Interview with multiple staff did not reveal any additional information to prove residents are being treated without dignity.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Iby Strong	TELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023

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-20230905103745

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: GOOD SAMARITAN RETIREMENT HOME	FACILITY NUMBER: 374600950
	VISIT DATE: 09/11/2023

NARRATIVE

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During investigation LPA did not find any information to corroborate the allegation.

Based on LPA's interviews, and record reviews there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegation is unsubstantiated. An exit interview was conducted with Director Susan Sorensen, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Iby Strong	TELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023

LIC9099 (FAS) - (06/04)

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