374602454-9-8-2021-08-AS-SJAB-C7BVQD-20210929163809

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374602454
Report Date: 09/08/2021
Date Signed: 09/08/2021 03:08:09 PM

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
06/05/2020 and conducted by Evaluator Daniel Pena

COMPLAINT CONTROL NUMBER: 08-AS-20200605142149

FACILITY NAME:	LA COSTA HEIGHTS LIVING CARE		FACILITY NUMBER:	374602454
ADMINISTRATOR:	LINDU NAPITUPULU		FACILITY TYPE:	740
ADDRESS:	7626 GALLEON WAY		TELEPHONE:	(760) 635-2870
CITY:	CARLSBAD	STATE: CA	ZIP CODE:	92009
CAPACITY:	6	CENSUS: 6	DATE:	09/08/2021
		UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Mildred Napitupulu, Licensee		TIME COMPLETED:	03:10 PM

ALLEGATION(S):

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Staff mismanaged residents medication

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Daniel Pena conducted a virtual visit to the facility to deliver findings for this complaint investigation. LPA identified himself to Licensee, Mildred Napitupulu, explained the purpose of the visit and discussed the investigative findings.

It was alleged that staff mismanaged Resident 1’s medications (LIC811 Confidential Names list provided to Licensee to identify R1). It was reported that the facility failed to administer one of R1’s medications for the period of June 1-3, 2020. During the course of the investigation, LPA conducted virtual visits to the facility due to COVID-19, reviewed facility, client and outside source records and interviewed facility staff, authorized representatives and outside agencies. Interviews with independent parties consistently stated that the facility was well run. These parties also said they have not encountered any problems with any of the services provided, including medication administration.

Records and interviews revealed that R1 lived at the La Costa Heights Living Care facility from 2013 until 2014.

Unfounded

Estimated Days of Completion: 90

SUPERVISOR'S NAME: John Rante	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021

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-20200605142149

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: LA COSTA HEIGHTS LIVING CARE	FACILITY NUMBER: 374602454
	VISIT DATE: 09/08/2021

NARRATIVE

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[Continued from LIC9099]

On November 1, 2014, R1 discharged from the facility and returned to their private residence. R1 did not return to the licensed care facility. Outside source records and interviews noted that R1 began receiving home care services on November 1, 2014. The home care service provider also operates the La Costa Heights Living Care facility which is also based in San Diego County and, per company records, provides non-medical services including a 24/7 caregiver. Interviews and outside agency records confirmed R1 contracted for home care services from November 2014 until passing at their residence in June 2020.

Record review and interviews consistently revealed that R1 was living in a private residence in June 2020, when the alleged violation occurred. The Community Care Licensing Division has no jurisdiction to investigate complaints which do not occur in licensed care facilities.

The Department has investigated the complaint that facility staff mismanaged R1’s medications. Based on the evidence gathered during this investigation, the allegation is Unfounded meaning that the allegation is false, could not have happened and/or is without a reasonable basis. The Department has therefore dismissed the complaint allegation.

An exit interview was conducted with Ms. Napitupulu and copies of this report and Licensee/Appeal Rights (LIC 9058 01/16), were provided to Administrator, Lindu Napitupulu via electronic mail. An electronic read receipt confirmation was requested to be sent by the Administrator upon receipt of the documents.

SUPERVISOR'S NAME: John Rante	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021

LIC9099 (FAS) - (06/04)

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