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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374601397
Report Date: 04/04/2023
Date Signed: 04/04/2023 11:35:15 AM

Unfounded


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
01/03/2023 and conducted by Evaluator Tricia Danielson
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230103152320
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:
04/04/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Cristina Agoscruz, CaregiverTIME COMPLETED:
09:30 AM
ALLEGATION(S):
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Facility is operating under another name
Facility staff prevent resident from getting out of bed
Facility staff do not provide activities for resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to conclude an investigation into the allegation listed above. LPA met with Caregiver Cristina Agoscruz and explained the purpose of the visit. LPA also spoke with Assistant Administrator Garrett Welker via telephone and explained the purpose of today's visit.
Regarding the allegation "Facility is operating under another name", it was alleged that the facility is operating under the name Kelly's Sunset Villa not Mary Katherine's Home IV. Interview conducted with Assistant Administrator Garrett Welker revealed the facility was purchased from the previous owners and the process of obtaining a new license and name are underway however the name and license for Mary Katherine's Home IV remains in place at this time. Records reviewed indicated the facility filed change of ownership documents with the department on 5/2/2022 to become Kelly's Sunset Villa but this change has not yet been completed.
Regarding the allegation "Facility staff prevent resident from getting out of bed", it was alleged that facility staff place R1's wheelchair at the side of their bed so as to prevent R1 from being able to get out of the bed. Interviews conducted with two (2) facility staff indicated there are no residents at the facility who have (CONTINUED ON LIC9099-C)
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (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.
LIC9099 (FAS) - (06/04)
Page: 1 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
01/03/2023 and conducted by Evaluator Tricia Danielson
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230103152320

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:
04/04/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Caregiver Cristina AgoscruzTIME COMPLETED:
09:30 AM
ALLEGATION(S):
1
2
3
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5
6
7
8
9
Facility staff are not meeting resident's incontinence needs
INVESTIGATION FINDINGS:
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5
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9
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Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to conclude an investigation into the allegations listed above. LPA met with Caregiver Cristina Agoscruz and explained the purpose of the visit. LPA also spoke with Assistant Administrator Garrett Welker via telephone and explained the purpose of today's visit.
Regarding the allegation "Facility staff are not meeting resident's incontinence needs", it was alleged that Resident #1 (R1) was not provided assistance with changing their adult brief nor was their brief checked from lunch time to evening on December 24, 2022. It was further alleged that R1's adult brief is not changed regularly. Interviews conducted with three (3) facility staff indicated residents are toileted when they wake up and before and after every meal. 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 are not toileted before and after every meal. Records reviewed for R1 revealed R1 is on a bowel and bladder program and is to receive assistance with toileting upon waking up each morning, before and after each meal, and their brief is to be checked every two hours. LPA visited the facility on January 6, 2023 from 1:00 PM to 3:15 PM and did not observe R1 toileted or have their brief checked during the two hour and fifteen minute 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: 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.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 18-AS-20230103152320
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: 04/04/2023
NARRATIVE
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(CONTINUED FROM LIC9099)
LPA also visited the facility on March 1, 2023 from 9:00 AM to 11:20 AM including lunch service. LPA did not observe R1 toileted or have their brief checked during the two hour and twenty minute visit.

Based on LPA’s observations, interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099 D. 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: 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
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20230103152320
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: 04/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/14/2023
Section Cited
CCR
87464(d)
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Basic Services- (d) A facility...chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457, Pre-admission Appraisal...either directly or through outside resources. This requirement was not met as evidenced by:
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The licensee states all staff will be re-trained regarding resident's documented plans of care. Proof of training will be submitted to LPA by POC due date of 4/14/2023.
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The licensee did not ensure basic services were provided. Based on records reviewed, R1 was not provided their toileting schedule as was required and documented in their pre-admission appraisal. This poses a potential health, safety, and 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: 04/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 18-AS-20230103152320
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: 04/04/2023
NARRATIVE
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(CONTINUED FROM LIC9099)
wandering behavior and only one (1) resident who is able to walk on their own. 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 are not barricaded in their bed and are able to walk about the facility should they desire. Records reviewed for R1 revealed R1 is non-ambulatory, frail/slow, requires a wheelchair or walker to move about the facility but must be assisted in doing so, is unable to walk without any physical assistance, and requires one to two person assistance to transfer from bed to wheelchair or wheelchair to bed. During a facility visit on March 1, 2023, LPA observed R1 to be reclined in a reclining chair watching TV and occasionally looking at a newspaper. At lunch time, two staff attempted to assist R1 to their feet to be able to be transferred to the wheelchair to go to the table for lunch. LPA observed R1 to be completely unable to stand without assistance from staff.
Regarding the allegation "Facility staff do not provide activities for resident", it was alleged that facility staff keep R1 in their wheelchair all day and do not do activities with them. Interviews conducted with two (2) facility staff indicated there are activities such as dominoes and puzzles available for any resident who would like to play, newspaper/magazine reading for current events, music/singing, and movies/TV. 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 the facility provides activities such as music, singing, TV, movies, newspapers and magazines. Review of R1's pre-placement appraisal revealed R1 was active with self, not very social or interested in social activities but loved to watch TV. As stated above, R1 was observed watching TV and looking at a newspaper during LPA's visit to the facility on March 1, 2023.

This agency has investigated the complaint alleging "Facility is operating under another name", "Facility staff prevent resident from getting out of bed", and "Facility staff do not provide activities for resident". We have found that the complaint was unfounded, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. 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: 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
LIC9099 (FAS) - (06/04)
Page: 5 of 5