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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374602208
Report Date: 12/14/2022
Date Signed: 12/14/2022 06:10:29 PM

Substantiated


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
11/29/2022 and conducted by Evaluator Marisela Garcia-Centeno
COMPLAINT CONTROL NUMBER: 08-AS-20221129141044
FACILITY NAME:SARASONA HOME CAREFACILITY NUMBER:
374602208
ADMINISTRATOR:ESTHER V. CAMAGAYFACILITY TYPE:
740
ADDRESS:3717 SARASONA WAYTELEPHONE:
(619) 434-6998
CITY:BONITASTATE: CAZIP CODE:
91902
CAPACITY:6CENSUS: 5DATE:
12/14/2022
UNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Administrator, Esther CamagayTIME COMPLETED:
05:10 PM
ALLEGATION(S):
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Staff did not do a pre-admission assessment
Licensee did not provide a 30-Day notice
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced visit to deliver investigative findings. LPA was greeted by Caregiver Virgilio Camagay, to whom she identified herself. LPA met with Administrator, Esther Camagay, to whom she discussed the purpose of the visit.

The Department investigated the above listed complaint allegations. The investigation consisted of a tour of the facility, multiple interviews with staff and outside sources, and records review, including client and facility records and other relevant evidence pertinent to this investigation.

On November 29, 2022, Community Care Licensing (CCL) received a complaint alleging that staff did not do an assessment of a resident prior to admission. On December 8, 2022 during a tour of the facility, it was observed that the resident in question was not present at the facility. Later during the visit, interviews with staff indicated the resident had been sent to the hospital for a non-emergency situation.
(Continue on LIC9099C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Marisela Garcia-CentenoTELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022
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-20221129141044
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: SARASONA HOME CARE
FACILITY NUMBER: 374602208
VISIT DATE: 12/14/2022
NARRATIVE
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(Continue from LIC9099)

The details of the allegation specifically indicated that the resident had been discharged from a hospital and admitted to the facility on November 2, 2022, without the licensee conducting a required preadmission assessment. During staff interviews administrator acknowledged that an in-person preadmission assessment was not completed due to visitation limitations in the hospital related to Coronavirus Disease of 2019 (COVID-19). Staff stated that they completed an assessment over the telephone with hospital staff. Facility staff stated that they relied on the information that was provided by the hospital to complete the Resident Appraisal (LIC 603A) during the admission process. The day after admission, facility staff observed the resident to have medical conditions needing a higher level of care that had not been communicated to the licensee by the hospital staff.

In addition, it was also alleged that the licensee did not provide a 30-day eviction notice once facility staff determined the resident’s medical condition needed a higher level of care than what they could provide. Interviews with staff and outside sources disclosed that although there were communications with resident’s family regarding the need to relocate resident to a different facility that could provide a higher level of care, a written 30-Day notice was not given to the resident or responsible party. Evidence obtained during the investigation determined that a voluntary relocation of the resident had initially been agreed to by all parties involved. However, once this decision changed, a 30-day notice should have been issued by the licensee along with a written reappraisal to indicate a higher level of care was now needed.

The Department has investigated the above-mentioned allegations and has found that there was sufficient evidence to corroborate the above allegations. Therefore, these allegations are deemed to be substantiated. A substantiated finding means the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies were cited per Title 22, Division 6, Chapter 8 of the California Code of Regulations and are listed on LIC 9099-D. A plan of corrections was developed with Administrator, Esther Camagay.

An exit interview was conducted with Administrator, Esther Camagay, to whom a copy of this report and Licensee Appeal Rights (9058 01/16) were provided at the conclusion of the visit.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Marisela Garcia-CentenoTELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 08-AS-20221129141044
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: SARASONA HOME CARE
FACILITY NUMBER: 374602208
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
01/20/2023
Section Cited
CCR
87457(c)
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87457(c) Pre-Admission Appraisal – General - Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs… This requirement was not met as evidenced by:
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Licensee will conduct additional training in Pre-Admission Appraisal requirements to all staff including licensee by a third party provider. Licensee will submit training records to CCL with completed training on or before POC date of 1/20/2023
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Based on observations, records review and staff interviews, licensee did not complete a pre-admission appraisal. This posed a potential health risk to 1 of 6 residents in care.
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Request Denied
Type B
01/20/2023
Section Cited
CCR
87224?(a)(4)
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87224 (a)(4)Eviction Procedures … Thirty (30) days written notice to the resident is required…. If, after admission, it is determined that the resident has a need not previously identified….

This requirement was not met as evidenced by:
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Licensee will conduct additional training in Eviction Procedures and requirements to all staff including licensee by a third party provider. Licensee will submit training records to CCL with completed training on or before POC date of 1/20/2023
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Based on observations and staff interviews, licensee did not provide a Thirty (30) days written notice. This posed a potential personal rights risk to 1 of 6 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: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Marisela Garcia-CentenoTELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3