374601397-4-4-2023-18-AS-TDAN-CQKPTZ-20230404113642

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374601397
Report Date: 04/04/2023
Date Signed: 04/04/2023 11:36:55 AM

Document Has Been Signed on 04/04/2023 11:36 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
ADMINISTRATOR:	KELSEY ROSAS-SIMMONS		FACILITY TYPE:	740
ADDRESS:	1205 SUNSET HEIGHTS ROAD		TELEPHONE:	(760) 415-6348
CITY:	ESCONDIDO	STATE: CA	ZIP CODE:	92026
CAPACITY:	6	CENSUS: 6	DATE:	04/04/2023
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Cristina Agroscruz, Caregiver		TIME COMPLETED:	11:45 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Tricia Danielson arrived to the facility to address concerns based on information received as an addendum to Complaint Control #18-AS-20230103152320. LPA met with Caregiver Cristina Agroscruz and explained the purpose of the visit. LPA spoke with Assistant Administrator Garrett Welker via telephone and also explained the purpose of today's visit. The addendum alleges residents are yelled at by staff specifically when "pooping" and after taking fruit to eat. Interviews conducted with two (2) facility staff indicated staff have not yelled at residents for any reason. Interviews were conducted with five (5) of six (6) residents. Only one (1) of five (5) residents interviewed was determined to be a reliable historian. The reliable historian resident interviewed reported they had not been yelled at by staff nor had they heard staff yelling at other residents. The addendum also alleges Resident #1 (R1) is made to go to bed at 5 PM against their will. Interviews conducted with two (2) facility staff indicated R1 goes to bed around 6:30 PM to 7:30 PM and will tell staff they are ready to go to bed. The reliable historian resident interviewed reported they are not made to go to bed at any specific time. R1 was unable to be interviewed. Also alleged in the addendum is R1 is served "a lot" of soup and Resident #2 (R2) is served cereal "all of the time". Interviews conducted with staff indicated soup is served on the average of one to two times weekly or more if residents request it. Per staff, R2 requests cereal for breakfast every day. The reliable historian resident interviewed reported the residents are served soup once weekly and cereal about two or three times weekly. R1 and R2 were unable to be interviewed. During a facility visit on March 1, 2023, as well as during today's visit, LPA was present during lunch service and neither soup nor cereal was served. The addendum additionally alleges R1 is strapped in their wheelchair without a physician's order to do so. Records reviewed did not produce a physician's order to secure R1 in a wheelchair with a seatbelt. During a facility visit on March 1, 2023, LPA inspected R1's wheelchair to discover there was no seatbelt or strap attached to it. The wheelchair did have a large cushion on the seat which normally utilized a strap to secure the cushion to the wheelchair however the strap was missing one half of the buckle. R1 was unable to be interviewed.(CONTINUED ON LIC809-C)

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/04/2023

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(CONTINUED FROM LIC809)
The addendum further alleges staff open the window of R1's room which causes R1 to be cold. Interviews conducted with two (2) facility staff revealed the window in R1's room has been opened in order to air the room out on occasion. Staff reported R1 is not usually in the room when the window is opened and if the window is open during a visit with friends/family, the window can be closed at any time. R1 was unable to be interviewed.
Lastly, the addendum alleges that once R1 was found in their bed wearing only a t-shirt and later was observed to have a cold. Interviews conducted with two (2) facility staff revealed if R1 expressed the desire to lay in their bed wearing only a t-shirt, they are permitted to do so. Records reviewed revealed no treatment orders for cold symptoms. R1 was unable to be interviewed.
Based on the information listed above, there are no deficiencies noted. An exit interview was conducted and a copy of this report was provided along with LIC811- Confidential Names list.

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023

LIC809 (FAS) - (06/04)

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