374601876-3-8-2022-08-AS-JRAE-CD22Z8-20220330174954

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374601876
Report Date: 03/08/2022
Date Signed: 03/08/2022 05:40:40 PM

Unsubstantiated

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
11/29/2021 and conducted by Evaluator Tiffany Holmes

COMPLAINT CONTROL NUMBER: 08-AS-20211129090249

FACILITY NAME:	MOFFAT'S ROSE HOME		FACILITY NUMBER:	374601876
ADMINISTRATOR:	TRINA PACKARD		FACILITY TYPE:	735
ADDRESS:	9019 ILDICA ST		TELEPHONE:	(619) 460-2030
CITY:	SPRING VALLEY	STATE: CA	ZIP CODE:	91977
CAPACITY:	6	CENSUS: 6	DATE:	03/08/2022
		UNANNOUNCED	TIME BEGAN:	12:10 PM
MET WITH:	Trina Packard, Administrator		TIME COMPLETED:	12:40 PM

ALLEGATION(S):

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Unlawful Eviction

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Tiffany Holmes, conducted an unannounced complaint visit to deliver findings on the above-mentioned allegations. LPA was granted entry into the facility after identifying himself and stating the purpose of the visit. LPA met with Administrator, Trina Packard.
The Department’s investigation included a review of facility records, interviews with staff, clients responsible parties and outside sources. It was alleged that an Unlawful Eviction was given to Client 1 (C1). Interviews revealed C1 went to the hospital for Covid on or around 11/14/2021. Interviews with staff revealed that C1 was due to come home on 11/19/2021. Hospital staff advised that C1 would need a home health aide. Staff was concerned about the return of C1 due to C1 not being able to do things independently. Prior to C1 going into the hospital they were ambulatory and could independently do their ADL's. Interviews revealed when the hospital called to get ready for discharge of C1 they explained that C1 would need assistance with showering and walking.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022

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-20211129090249

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: MOFFAT'S ROSE HOME	FACILITY NUMBER: 374601876
	VISIT DATE: 03/08/2022

NARRATIVE

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Interviews revealed that staff advised the hospital they would have to observe and reassess C1 prior to their return. While C1 was at the hospital the facility had an Health care associated Infections (HAI) visit on 11/19/2021. The report documenting the visit does request that staff get fit tested for N95s when dealing with a client that has tested positive for Covid. Interviews revealed staff did not have an issue with the client coming back to their home since they have lived there since 2004. They wanted to follow protocol from the County of San Diego health care nurse that explained the importance of the N95 fit testing to protect the staff and other clients. Interviews revealed that the one staff that would be working directly with C1 was fit tested on November 27, 2021. There were 4 staff in total that were fit tested on November 30, 2021 that could work with C1 when they returned. Interviews revealed that staff did not once state that the client couldn't come back to the facility. C1 returned to the facility on 11/30/2021.

The allegation is unsubstantiated. An exit interview was conducted with Trina Packard. A copy of this report and Licensee Appeal Rights (9058 01/16) were emailed to Administrator after the conclusion of the visit, LPA Holmes requested an electronic message reply to confirm receipt of these documents.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2022

LIC9099 (FAS) - (06/04)

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