374602302-2-26-2024-08-AS-JLOT-D3BK53-20240313073517

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374602302
Report Date: 02/26/2024
Date Signed: 02/26/2024 03:09:38 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 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
02/01/2024 and conducted by Evaluator Nacole Patterson

PUBLIC

COMPLAINT CONTROL NUMBER: 08-AS-20240201112810

FACILITY NAME:	LA COSTA HEIGHTS ASSISTED LIVING		FACILITY NUMBER:	374602302
ADMINISTRATOR:	LINDU NAPITUPULU		FACILITY TYPE:	740
ADDRESS:	3111 LEVANTE ST		TELEPHONE:	(760) 634-2870
CITY:	CARLSBAD	STATE: CA	ZIP CODE:	92009
CAPACITY:	6	CENSUS: 5	DATE:	02/26/2024
		UNANNOUNCED	TIME BEGAN:	02:10 PM
MET WITH:	Lindu and Mildred Napitupulu, Licensees		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff did not ensure resident's care needs were met.
Staff did not provide adequate food service to residents.
Staff did not administer resident's medication as prescribed.
Staff did not provide resident with clean linen.
Staff did not treat resident(s) with dignity.
Licensee did not comply with terms of the admission agreement.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Licensees Lindu and Mildred Napitupulu.

On 2/1/24 it was alleged that staff did not ensure resident's care needs were met, staff did not provide adequate food service to residents, staff did not administer resident's medication as prescribed, staff did not provide resident with clean linen, staff did not treat resident(s) with dignity, and Licensee did not comply with terms of the admission agreement. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, records review, and LPA observations.

(Continued on LIC9099-C p.2)

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Nacole Patterson	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 02/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2024

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 6

Control Number 08-AS-20240201112810

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: LA COSTA HEIGHTS ASSISTED LIVING	FACILITY NUMBER: 374602302
	VISIT DATE: 02/26/2024

NARRATIVE

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(Continued from LIC9099 p.1)

Regarding the allegation, "Staff did not ensure resident's care needs were met", it was alleged that staff did not respond to Resident 1 (R1)'s call at night, and did not assist them with incontinence care. Staff interviews revealed that R1 lived at the facility for two (2) days, and staff checked on R1 each night, including responding to their calls. Staff interview further revealed that staff and Hospice monitored R1's incontinence care system on both days R1 lived at the facility, and it was changed both days, once by an Outside Individual (OI) related to R1 on 1/23/24, and then by Hospice on 1/24/24. The Licensee informed that they personally checked the system the day R1 moved in, on 1/23/24. R1 moved out the morning of 1/25/24.

Resident interviews did not corroborate the allegation, residents informed that staff assisted them with all care needs. No resident informed that staff did not assist them with incontinence care.

Outside source interviews did not corroborate the allegation. One outside source had not received any concerns about incontinence needs not being met at the facility, and did not observe any concerning issues during past visits. Interview with a second outside source confirmed that R1 was at the facility for 2 days, and that the Hospice agency changed the incontinence care system during one of the visits.

Review of charting notes on 1/23/24 at 11:30am showed that the resident's incontinence care system was checked upon admission, corroborating staff statements that staff were monitoring it.

R1 was unable to be interviewed due to no longer living at the facility.

Regarding the allegation, "Staff did not provide adequate food service to residents", it was alleged that staff did not offer resident(s) fresh food. Staff interview revealed that the facility consistently kept a number of fresh fruits on hand such as bananas, apples, honeydew, strawberries, watermelon, cantaloupe, and grapes. Staff interview revealed that staff ask residents what they would like to eat each meal, and then prepare it fresh. Staff interview revealed that R1 refused to eat most of the time they lived at the facility and informed staff that they wanted to go home, refusing to eat.

(Continued on LIC9099-C p.3)

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Nacole Patterson	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 02/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 08-AS-20240201112810

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: LA COSTA HEIGHTS ASSISTED LIVING	FACILITY NUMBER: 374602302
	VISIT DATE: 02/26/2024

NARRATIVE

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(Continued from LIC9099-C p.2)

Resident interviews corroborated staff statements that fresh fruits and vegetables were offered to residents. Residents stated that they got to choose what they would like to eat during the day and enjoyed eating cereal, puffy omelets, bananas, and oatmeal. Resident interviews further revealed that while some residents chose not to eat fresh fruit, staff still offered it to them and other residents were observed eating fresh fruit.

Outside source interviews did not corroborate the allegation. Outside sources had not observed or been informed of residents being denied fresh food at the facility.

No records were found to support the allegation.

LPA directly observed fresh fruits and vegetables at the facility during unannounced facility visits. During a visit on 2/7/24, LPA observed watermelon, strawberries, grapes, apples, onions, cucumbers, tomatoes, and pasta salad in the refrigerator. LPA conducted a Required Annual Inspection on 11/22/23 and observed the facility to have more than the required amount of 2 days perishable food and 7 days non-perishable food, all properly stored and within expiration dates.

Regarding the allegation, "Staff did not administer resident's medication as prescribed", it was alleged that staff did not provide R1 with a medication at night. Staff interview revealed that the medication in question was a pro re nata (PRN) "as needed" prescription for pain, which R1 asked for and was given both nights they lived at the facility.

Resident interviews did not corroborate the allegation, residents stated that their medications were given accurately and on time with no issues.

Outside source interviews did not corroborate the allegation, informing that they had not observed medication errors at the facility and had not been notified of errors.

(Continued on LIC9099-C p. 4)

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Nacole Patterson	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 02/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 08-AS-20240201112810

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: LA COSTA HEIGHTS ASSISTED LIVING	FACILITY NUMBER: 374602302
	VISIT DATE: 02/26/2024

NARRATIVE

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(Continued from LIC9099-C p.3)

Records Review corroborated staff statements that R1 was provided their PRN the evening of 1/23/24 and 1/24/24.

R1 was unable to be interviewed due to no longer living at the facility.

Regarding the allegation, "Staff did not provide resident with clean linen", it was alleged that the Licensee did not provide linens for R1's bed upon move in. Staff interviews revealed that R1's facility-provided bed was made up with linens upon admission, and when the Hospice bed was delivered, staff re-made the new bed with linens as well.

Resident interviews revealed no concerns regarding clean linens, residents informed that their linens were cleaned regularly and/or upon request, including bed pads.

Outside sources interviewed did not have concerns regarding the linens being changed regularly. Outside sources informed that it was customary for Hospice beds to be delivered without linens. Outside sources informed that the facility provided R1 with clean linens initially on the facility-provided bed, and the Hospice bed once it had arrived.

No records were found to corroborate the allegation.

During the facility visit LPA observed resident rooms to have the required bedding layers, which were clean and in good repair. LPA did not observe any stains, debris, or particles that would indicate that the linens had not been washed recently. LPA also did not observe any odors in the facility that would indicate that the linens were not washed regularly. During a facility visit on 2/7/24 LPA observed staff washing and folding laundry.

R1 was unable to be interviewed due to no longer living at the facility.

(Continued on LIC9099-C p.5)

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Nacole Patterson	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 02/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 08-AS-20240201112810

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: LA COSTA HEIGHTS ASSISTED LIVING	FACILITY NUMBER: 374602302
	VISIT DATE: 02/26/2024

NARRATIVE

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(Continued from LIC9099-C p.4)

Regarding the allegation, "Staff did not treat resident(s) with dignity", it was alleged that staff spoke rudely to a resident. Staff interviews did not corroborate the allegation, staff informed that they had never heard another staff member speak rudely to a resident or yell at them. Staff informed that sometimes a specific resident had to be instructed back to their room during elevated behaviors, but staff did not speak rudely when doing so.

Resident interviews did not corroborate the allegation, residents informed that staff were nice, respectful, and caring. No resident had heard staff speak rudely or yell at another resident. Resident interviews revealed that even when residents were rude to staff, staff respond respectfully and without yelling.

Outside source interviews did not corroborate the allegation, having no concerns about staff treating residents with dignity. Outside sources had not been informed of, nor had they observed dignity issues at the facility.

No records were found to corroborate the allegation.

During unannounced facility visits, LPA observed staff engaging with residents in a calm, respectful manner. LPA did not observe any staff raise their voice or attempt to force a resident to do something outside of their will.

Regarding the allegation, "Licensee did not comply with terms of the admission agreement", it was alleged that the Licensee did not issue R1 and their Responsible Party a refund for unused rent, per the admissions agreement. Staff interview revealed that the funds were not returned because R1 and their Responsible Party violated the signed admission agreement requiring residents to give a 30-day notice upon move out. Staff statements were corroborated by review of R1's admission agreement, which was initialed and signed by R1's Responsible Party. No records were found to support that R1 and/or their Responsible Party provided the 30 day notice to vacate the facility, as required.

(Continued on LIC9099-C p.6)

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Nacole Patterson	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 02/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 08-AS-20240201112810

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: LA COSTA HEIGHTS ASSISTED LIVING	FACILITY NUMBER: 374602302
	VISIT DATE: 02/26/2024

NARRATIVE

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(Continued from LIC9099-C p.6)

R1 was unable to be interviewed due to no longer living at the facility.

Outside source interviews did not corroborate the allegation. One outside source had not received concerns regarding admission agreement violations by the Licensee. A second outside source confirmed that R1 and their Responsible Party violated their admission agreement by not providing a 30-day notice before moving R1 out of the facility.

Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation(s) occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Lindu and Mildred Napitupulu, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Nacole Patterson	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 02/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2024

LIC9099 (FAS) - (06/04)

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