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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374601397
Report Date: 03/01/2023
Date Signed: 03/01/2023 11:04:57 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/21/2023 and conducted by Evaluator Tricia Danielson
COMPLAINT CONTROL NUMBER: 18-AS-20230221111939
FACILITY NAME:MARY KATHERINE'S HOME IVFACILITY NUMBER:
374601397
ADMINISTRATOR:KELSEY ROSAS-SIMMONSFACILITY TYPE:
740
ADDRESS:1205 SUNSET HEIGHTS ROADTELEPHONE:
(760) 415-6348
CITY:ESCONDIDOSTATE: CAZIP CODE:
92026
CAPACITY:6CENSUS: 6DATE:
03/01/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Cristina Agoscruz, CaregiverTIME COMPLETED:
11:20 AM
ALLEGATION(S):
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Staff are not allowing family member to visit resident
Staff did not allow private caregiver in the home
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to initiate an investigation into the allegtions listed above. LPA met with Caregiver Cristina Agoscruz and explained the purpose of the visit. LPA also spoke with Assistant Administrator (AA) Garrett Welker via telephone.
During today's visit, LPA interviewed two (2) staff, one (1) resident, reviewed and obtained copies of pertinent documents related to Resident #1 (R1), and toured the facility.
Regarding the allegations "Staff are not allowing family member to visit resident" and "Staff did not allow private caregiver in the home", it was alleged that R1's Power of Attorney (POA) had informed the facility to restrict any visitors for R1 unless the POA approved or was present at the time of the visit. LPA had previously spoken via telephone to AA Welker on 2/17/2023 and Licensee Kelly Welker on 2/20/2023 regarding this issue. During those conversations, the Welker's sought guidance regarding the POA's right to restrict R1's visitors after disallowing visitation for R1 at the direction of R1's POA. LPA provided regulatory information regarding every resident's right to have or refuse a visit of family, friends, or otherwise as well information concerning the inability of any POA to restrict a visit to a resident. The Welker's conveyed understanding of the regulation and have since implemented changes to ensure any resident may have a visitor should they desire a visit. (CONTINUED ON LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023
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 18-AS-20230221111939
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MARY KATHERINE'S HOME IV
FACILITY NUMBER: 374601397
VISIT DATE: 03/01/2023
NARRATIVE
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(CONTINUED FROM LIC9099)
Based on LPA’s interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099 D. The citation was cleared at the time of the visit due to the facility's already implemented visitation policy correction.

An exit interview was conducted and a copy of this report was provided along with LIC811- Confidential Names list and Appeal Rights.

SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 18-AS-20230221111939
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MARY KATHERINE'S HOME IV
FACILITY NUMBER: 374601397
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/01/2023
Section Cited
CCR
87468.2(a)(21)
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Additional Personal Rights of Residents in Privately Operated Facilities-(a) In addition to the rights listed in Section 87468.1...residents in...residential care facilities for the elderly shall have all of the following personal rights:(21)To consent to have their relatives...of their choosing visit...without prior notice. This requirement was not met as evidenced by:
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The citation was cleared at the time of the visit due to the facility's already implemented visitation policy correction and acknowledged understanding of R1's right to choose visitors and the POA's inability to restrict visitors for R1.
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The licensee did not ensure residents personal rights were maintained by allowing visitors of their choice. Based on interviews, the facility disallowed R1 visitors based on the direction of R1's POA. This poses an immediate personal rights risk to 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: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023
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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/21/2023 and conducted by Evaluator Tricia Danielson
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230221111939

FACILITY NAME:MARY KATHERINE'S HOME IVFACILITY NUMBER:
374601397
ADMINISTRATOR:KELSEY ROSAS-SIMMONSFACILITY TYPE:
740
ADDRESS:1205 SUNSET HEIGHTS ROADTELEPHONE:
(760) 415-6348
CITY:ESCONDIDOSTATE: CAZIP CODE:
92026
CAPACITY:6CENSUS: 6DATE:
03/01/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Cristina Agoscruz, CaregiverTIME COMPLETED:
11:20 AM
ALLEGATION(S):
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9
Staff are overmedicating resident
Staff are restraining resident in wheelchair
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to initiate an investigation into the allegtions listed above. LPA met with Caregiver Cristina Agoscruz and explained the purpose of the visit. LPA also spoke with Assistant Administrator (AA) Garrett Welker via telephone.
During today's visit, LPA interviewed two (2) staff, one (1) resident, reviewed and obtained copies of pertinent documents related to Resident #1 (R1), and toured the facility.
Regarding the allegation "Staff are overmedicating resident", it was alleged that Resident #1(R1) was "out of it" during a recent family visit. Review of R1's Medication Administration Records (MARs) revealed R1 is prescribed Seroquel at bedtime to assist with agitation however, it is ordered to be given on an as needed basis. Review of R1's MARs revealed they were provided this medication thirteen (13) times in the month of February. R1 is not prescribed any narcotic type medications. Interview with staff revealed R1 takes Seroquel to help relieve agitation symptoms due to sundowning behavior.
Regarding the allegation "Staff are restraining resident in wheelchair", it was alleged that facility staff are "strapping" R1 in the wheelchair and it was unknown if there was a physician's order to do so. Interviews conducted with facility staff revealed R1 frequently wears a gait belt to assist staff in transferring (CONTINUED ON LIC9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023
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 18-AS-20230221111939
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MARY KATHERINE'S HOME IV
FACILITY NUMBER: 374601397
VISIT DATE: 03/01/2023
NARRATIVE
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(CONTINUED FROM LIC9099-A)
and toileting activities, but is not confined to a wheelchair with any belt. Review of R1's file did not reveal any physician's order to restrain them in the wheelchair. LPA observed R1's wheelchair and discovered there is no seatbelt or strapping device available. There was a cushion on the wheelchair which did have a buckle type strap to secure it to the wheelchair however one half of the buckle was missing and therefore would not have been able to be used as a restraint. LPA also spoke to R1 during today's visit and did not observe a gait belt or R1 to be restrained in any way. During a previous visit and conversation with R1, LPA did observe them to be wearing a gait belt but it was not secured to the wheelchair in any way.
Although the allegations may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are unsubstantiated.
An exit interview was conducted and a copy of this report was provided along with LIC811- Confidential Names list.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5