374602155-4-14-2023-18-AS-JESL-CR9PBS-20230426111048

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374602155
Report Date: 04/14/2023
Date Signed: 04/14/2023 11:26:41 AM

Substantiated

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
05/09/2022 and conducted by Evaluator Jesse Gardner

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20220509165501

FACILITY NAME:	TWIN OAKS MANOR		FACILITY NUMBER:	374602155
ADMINISTRATOR:	LOLITA V. GATMAITAN		FACILITY TYPE:	740
ADDRESS:	1719 MEDINAH		TELEPHONE:	(760) 798-1588
CITY:	SAN MARCOS	STATE: CA	ZIP CODE:	92069
CAPACITY:	5	CENSUS: 3	DATE:	04/14/2023
		UNANNOUNCED	TIME BEGAN:	10:50 AM
MET WITH:	Lolita Gatmaitan, Administrator		TIME COMPLETED:	11:25 AM

ALLEGATION(S):

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Physical abuse to residents in care by staff member.

INVESTIGATION FINDINGS:

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Licensing Program Analyst Jesse Gardner met with Administrator/Licensee Lolita Gatmaitan to deliver findings on the above allegation.

On May 9, 2022 the department received a complaint allegation for “physical abuse to residents in care by staff member.” On May 5, 2022, at about 1030 hours, Staff #1 (S1) arrived at the facility. The licensee said that S1 was agitated and becoming more erratic. The licensee along with Staff #3 (S3) attempted several ways to deescalate S1’s behavior.

Continued on LIC9099-C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Jesse Gardner	TELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

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 18-AS-20220509165501

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: TWIN OAKS MANOR	FACILITY NUMBER: 374602155
	VISIT DATE: 04/14/2023

NARRATIVE

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At about 1100 hours S1 entered into Resident’s #1 (R1) bedroom and begun to assault resident by punching R1 multiple times in the face and striking multiple times to R1’s chest and stomach. The licensee had followed S1 into R1’s bedroom where the licensee immediately intervened placing herself between R1 and S1. S1 shoved the licensee and punched her several times in the face and chest area while also knee thrusting the licensee in the abdomen. During this time, Resident #2 (R2) walked into the hallway where R2 was assaulted and slapped in the face several times by S1. S3 attempted to help R2 and was also slapped by S1. S1 walked outside the facility and staff called 911 while also locking the front door to keep S1 from re-entering the facility. Local law enforcement arrived on scene at about 1233 hours and arrested S1 without incident.

Staff and residents were attended to by medical professionals. As a result of S1’s behavior, the residents and staff suffered the following injuries: R1 sustained a small cut above the right eye and two black eyes, the licensee complained of pain in her back and head, S3 sustained a scratch on the right forearm.

S1 was arrested and charged with three counts of 368 (B) (1) PC- Cause Harm/Death of Elder /Dependent Adult (F), and one count of 243 (A) PC Battery on a person (M). In addition, S1 was provided a no contact notice and was removed from the staff roster.

Based on interviews which were conducted and records review, 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 3) is being cited on the attached LIC 9099D).

A copy of this report, appeal rights, and 9099D was discussed and provided to the Licensee/ Administrator.

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Jesse Gardner	TELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20220509165501

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: TWIN OAKS MANOR	FACILITY NUMBER: 374602155
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/14/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/21/2023 Section Cited HSC 1569.269(a)(1)(10)	1 2 3 4 5 6 7	Enumerated Rights; Severability-Residents of residential care facilities for the elderly shall have all of the following rights: To be accorded dignity in their personal relationships with staff, residents, and other persons and to be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. These requirements were not met based upon interviews and a review of records.	1 2 3 4 5 6 7	Licensee agrees that the involved staff will no longer be allowed inside the facility. In-service training was conducted by the Licensee regarding resident personal rights. POC cleared.
	8 9 10 11 12 13 14	This was not met as evidenced by - The licensee did not ensure that residents were free from physical abuse on May 5, 2022 S1 hit R1, R2 Licensee and Staff causing several injuries to R1, Licensee and staff. This is an immediate health and safety risk to residents 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: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Jesse Gardner	TELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

LIC9099 (FAS) - (06/04)

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