374601685-2-18-2022-08-AS-IESA-CC46K9-20220228195223

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374601685
Report Date: 02/18/2022
Date Signed: 02/18/2022 02:40:22 PM

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
08/04/2021 and conducted by Evaluator Kristina Ryan

COMPLAINT CONTROL NUMBER: 08-AS-20210804161658

FACILITY NAME:	REGENCY FALLBROOK		FACILITY NUMBER:	374601685
ADMINISTRATOR:	RIDENOUR, JASMINE		FACILITY TYPE:	740
ADDRESS:	609 E.ELDER STREET		TELEPHONE:	(760) 728-8504
CITY:	FALLBROOK	STATE: CA	ZIP CODE:	92028
CAPACITY:	75	CENSUS: 49	DATE:	02/18/2022
		UNANNOUNCED	TIME BEGAN:	11:06 AM
MET WITH:	Kari Moreno, Administrator		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Staff caused injury to resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Kristina Ryan, conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegation. LPA was allowed entry into the facility after identifying herself and stating the purpose of the visit. LPA met with Administrator, Kari Moreno.

The Department’s investigation consisted of a review of facility administrative and care records. It also involved interviews with facility staff, residents and outside sources.
The Department received a complaint on August 4, 2021, alleging that facility staff caused injury to resident. Interviews with the facility staff and with outside sources revealed that Resident 1 (R1) was a resident at the facility and that they were receiving assistance with activities of daily living and medication management. On July 17, 2021, R1 received a routine medication. During the administration of the medication, R1 became concerned that the medication provided was not correct. When R1 stated that they wanted to retain the medication for another staff to look at, Staff 1 (S1) forcefully removed the medication from R1’s hand causing bruising to R1’s bicep.

[CONTINUED ON LIC 9099-C, 1 of 2]

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Kristina Ryan	TELEPHONE: (619) 929-1438
LICENSING EVALUATOR SIGNATURE:	DATE: 02/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2022

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 3

Control Number 08-AS-20210804161658

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: REGENCY FALLBROOK	FACILITY NUMBER: 374601685
	VISIT DATE: 02/18/2022

NARRATIVE

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Interviews and review of facility records revealed that although this incident was unwitnessed by other parties, there was bruising noted to R1’s arm on July 18, 2021. On July 21, 2021, S1 admitted to “grabbing R1’s wrist”. S1 was subsequently fired. Interviews with other residents corroborate that there were no other victims and this incident appears to be an isolated event. A review of the facilities medication administration record reveals that medications were administered correctly and that the routine medication that R1 was provided on July 17, 2021 was correct.

On July 21, 2021 the facility self-reported the incident to Community Care Licensing, and assisted R1 with filing a police report. During the interview process with R1, the department was able to qualify R1 and R1’s statement was consistent with the report made by the facility to Community Care Licensing. R1 desired prosecution for the incident involving S1 and the police report corroborates the information provided to Community Care Licensing by the facility. Interviews with staff, residents and a review of administrative paperwork reveal that S1 was terminated on July 21, 2021.

Based on interviews, and reviewed records, a preponderance of evidence exists to substantiate the allegation. A deficiency is cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly created with the administrator and an exit interview was conducted with Kari Moreno, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058 01/16) were provided via e-mail.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Kristina Ryan	TELEPHONE: (619) 929-1438
LICENSING EVALUATOR SIGNATURE:	DATE: 02/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 08-AS-20210804161658

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: REGENCY FALLBROOK	FACILITY NUMBER: 374601685
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/18/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/18/2022 Section Cited CCR 87468.1(a)(3)	1 2 3 4 5 6 7	Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation,... This requirement was not met as evidenced by;	1 2 3 4 5 6 7	Administrator agreed to an all staff inservice regarding personal rights and mandated abuse reporting. Inservice topics and attendance sheet will be submitted to LPA on or before March 4, 2022.
	8 9 10 11 12 13 14	Based on interviews and records review, the licensee did not ensure that residents were free from humiliation for 1 of 53 persons in care which posed a potential Personal Rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Kristina Ryan	TELEPHONE: (619) 929-1438
LICENSING EVALUATOR SIGNATURE:	DATE: 02/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2022

LIC9099 (FAS) - (06/04)

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