374602052-6-18-2025-08-AS-SJAB-DHTRMF-20250620130838

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374602052
Report Date: 06/18/2025
Date Signed: 06/18/2025 06:07:22 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
08/16/2021 and conducted by Evaluator Dang Nguyen

COMPLAINT CONTROL NUMBER: 08-AS-20210816162242

FACILITY NAME:	OLIVENHAIN GUEST HOME		FACILITY NUMBER:	374602052
ADMINISTRATOR:	KAREN KANAN		FACILITY TYPE:	740
ADDRESS:	350 COLE RANCH ROAD		TELEPHONE:	(760) 753-5082
CITY:	ENCINITAS	STATE: CA	ZIP CODE:	92024
CAPACITY:	0	CENSUS: 0	DATE:	06/18/2025
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	N/A. Report Certified Mailed to Licensee.		TIME COMPLETED:	06:00 PM

ALLEGATION(S):

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-Licensee did not monitor resident’s medical device.
-Licensee did not meet resident’s incontinence needs.
-Licensee did not follow resident’s plan of care.
-Licensee did not maintain bathroom sanitation.
-Licensee did not observe infection control.
-Licensee did not meet reporting requirements.
-Licensee did not provide resident’s representative access to records within required timeframe.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Dang Nguyen concluded an investigation regarding the above prior complaint allegations. Since the facility ceased operations on 10/17/2022 due to Change in Ownership, the allegation findings were delivered to the Licensee via USPS certified mail.

The Complainant alleged that Licensee did not monitor Resident #1’s (R1’s) medical device, that Licensee did not meet R1’s incontinence needs, that Licensee did not follow R1’s plan of care, that Licensee did not maintain bathroom sanitation, that Licensee did not observe infection control, that Licensee did not meet reporting requirements, and that Licensee did not provide R1’s representative access to records within required timeframe. [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] CCLD’s investigation involved an unannounced facility tour/welfare check, review of relevant records, and interviews of pertinent staff and outside sources. R1 was not interviewed for this case because they had moved out by the time the complaint was filed and all parties agreed that R1 was memory impaired. [CONTINUED ON LIC 9099-C, 1 of 3]

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025

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 4

Control Number 08-AS-20210816162242

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: OLIVENHAIN GUEST HOME	FACILITY NUMBER: 374602052
	VISIT DATE: 06/18/2025

NARRATIVE

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[CONTINUED FROM LIC 9099]

Interviews aligned to show: R1, who had a pacemaker inside themselves, also had a pacemaker monitor/transmitter device which they kept in their bedroom at the facility. The monitor/transmitter was required to remain continuously powered-on and plugged into a surge protector strip so that it could send real-time data to R1’s cardiologist. When it was working correctly, the monitor/transmitter device would show a green status light. The Complainant said that during a facility visit in June 2021, they saw a yellow status light illuminated, which facility staff failed to observe for nearly a week. The Complainant said there were also occasions when they saw this device plugged directly into the wall outlet instead of the surge protector strip.

CCLD requested but did not receive evidence showing that R1’s pacemaker monitor/transmitter had been faulty/offline (i.e. “yellow” light status) for the claimed duration. LPA interviewed multiple facility staff, whose interviews aligned to show: Staff were well-familiar with R1’s device and knew that it needed to be both powered-on and plugged into the surge protector, with the status light illuminated green. They verified that this was the case whenever they entered R1’s bedroom. R1 on some occasions had unplugged the surge protector themselves to plug in their own cell phone charger, despite staff redirection/instruction to not do this and staff explaining to R1 there were other open ports on the surge protector strip that they could use for their phone. The preponderance of available evidence showed staff conscientiousness towards R1’s pacemaker monitor/transmitter.

Staff interviews aligned to show: R1 walked slowly with their walker device. R1 had some bowel/bladder sensation but wore Depends/briefs as insurance. R1 generally disliked asking for assistance and would try to go to the bathroom on their own. Knowing this, staff usually proactively asked R1 if they needed to use the restroom, which R1 often denied. When staff saw R1 walk in the direction of the bathroom, they would follow R1 to the bathroom to provide help. CCLD could not find evidence to corroborate that R1’s incontinence products were not timely changed. During his own 08/25/2021 facility visit, LPA did not detect urine or fecal odors emanating from residents he encountered. LPA also inspected multiple resident bedrooms, finding rooms and bedding were consistently clean and free of odors.

[CONTINUED ON LIC 9099-C, 2 of 3]

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 08-AS-20210816162242

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: OLIVENHAIN GUEST HOME	FACILITY NUMBER: 374602052
	VISIT DATE: 06/18/2025

NARRATIVE

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[CONTINUED FROM LIC 9099-C, 1 of 3]

Interviews aligned to show: Since time of move-in, R1 had a mobile seat-assist lift device (which they sat on top of) which would help push them up/out when it was time to transfer out of a chair. The Complaint said on 08/15/2021 (which was also R1’s last day living at the facility) they witnessed R1 not using said device, making it harder for R1 to transfer. The Complaint claimed Licensee unilaterally discontinued the device (i.e., without the consent of R1’s responsible person). Staff interviews aligned to show: R1 continued to use their seat-assist lift device throughout their residency. Direct care staff daily carried and moved the device to whatever chair R1 chose to sit in.

The Complainant alleged they saw feces on the floor of the facility’s shared bathrooms on multiple occasions. Staff interviews aligned to show: 100% of the facility’s residents were memory-impaired, yet several were able to walk to the bathroom on their own. Residents sometimes had incontinence episodes which required staff cleaning of the shared bathrooms. For example, some residents involuntarily defecated during showers when they felt warm water on their skin. However, caregivers timely cleaned up after residents, then housekeepers were called over to disinfect affected areas. Incontinence incidents aside, staff routinely cleaned the shared bathrooms at least twice per day, with bleach. During the investigation of this allegation, CCLD made two (2) unannounced site visits to the facility. During his 08/25/2021 visit, LPA Nguyen entered each of the facility’s shared restrooms, finding all were clean. There were no urine or feces on the floor or fixtures. The bathrooms were free of odors. Two (2) housekeepers were on duty and actively cleaning. During a subsequent 05/10/2022 visit, a different LPA toured the facility, also finding no obvious health or safety concerns.

The Complainant said that Licensee maintained a collection of brimmed outdoor hats (meant to protect residents from the sun when doing outdoor activities) which were shared amongst residents, and thus a vector for infection. However, interviews of facility staff showed that these hats were disinfected in between use, which met regulatory requirements for shared activity equipment.

[CONTINUED ON LIC 9099-C, 3 of 3]

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 08-AS-20210816162242

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: OLIVENHAIN GUEST HOME	FACILITY NUMBER: 374602052
	VISIT DATE: 06/18/2025

NARRATIVE

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[CONTINUED FROM LIC 9099-C, 2 of 3]

The Complainant said R1 had a fall at the facility around 08/12/2021 which resulted in a subsequent bruise on/near their right hip (but no other injury), and that Licensee did not report the fall or bruise to R1’s responsible person, who later discovered the bruise on their own. Subsequent interview of the responsible person gave a conflicting account, showing that Licensee reported the incident to them within 24 hours. Interviews of staff showed after R1 fell at the facility, R1 was able to get back up with staff assistance and that their post-fall assessment did not show any need for medical attention. (CCLD does not require a written incident report from Licensees for minor falls.)

The Complainant said on 08/15/2021, R1’s responsible person asked a manager for the facility’s written “nursing notes” on R1, but that these notes were not given to the responsible person within the required timeframe. Manager interview disputed this. CCLD was unable to obtain a preponderance of evidence to corroborate this claim.

Based on records and interviews, a preponderance of evidence does not exist to show that Licensee did not monitor resident’s medical device, that Licensee did not meet resident’s incontinence needs, that Licensee did not follow resident’s plan of care, that Licensee did not maintain bathroom sanitation, that Licensee did not observe infection control, that Licensee did not meet reporting requirements, or that Licensee did not provide resident’s representative access to records within required timeframe. These allegations are therefore Unsubstantiated, and no deficiencies were cited for them.

A copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were mailed to the Licensee’s last known address via USPS certified mail.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025

LIC9099 (FAS) - (06/04)

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