374602472-7-22-2024-08-AS-JLOT-D8MV2M-20240830160322

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374602472
Report Date: 07/22/2024
Date Signed: 07/22/2024 02:59:00 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
04/18/2024 and conducted by Evaluator Carmen Lopez

PUBLIC

COMPLAINT CONTROL NUMBER: 08-AS-20240418105131

FACILITY NAME:	SUN AND SEA ASSISTED LIVING		FACILITY NUMBER:	374602472
ADMINISTRATOR:	ANNE OWENS STONE		FACILITY TYPE:	740
ADDRESS:	740 SEVENTH STREET		TELEPHONE:	(619) 429-0633
CITY:	IMPERIAL BEACH	STATE: CA	ZIP CODE:	91932
CAPACITY:	32	CENSUS: 24	DATE:	07/22/2024
		UNANNOUNCED	TIME BEGAN:	02:05 PM
MET WITH:	Jay Agustine, Executive Director		TIME COMPLETED:	02:40 PM

ALLEGATION(S):

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- Staff physically abused resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced visit to deliver findings for a complaint investigation. LPA investigated and delivered findings regarding the above-mentioned allegation. LPA identified herself and was granted entry by Sharon Hays, Activities Coordinator. LPA stated the purpose of the visit and reviewed the findings of the complaint with Executive Director Jay Agustine.

The Department’s investigation consisted of interviews with staff, resident, and outside sources, and records review of relevant documents pertinent to this investigation. On April 18, 2024, it was alleged that the facility staff physically abused a resident.

It was specifically alleged that the facility staff kicked resident on her back. Interview with resident #1 (R1) showed that they were confused as they first reported to LPA that it was hospital staff who pushed them. R1 later contradicted themselves and said that it was facility staff who had pushed them. R1 was unable to keep their conversation centralized to one topic during the interview.
(Continuation on LIC9009-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) -34-3976
LICENSING EVALUATOR NAME: Carmen Lopez	TELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024

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-20240418105131

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: SUN AND SEA ASSISTED LIVING	FACILITY NUMBER: 374602472
	VISIT DATE: 07/22/2024

NARRATIVE

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(Continuation of LIC9099)

LPA attempted to redirect the conversation, but the resident was forgetful and would continuously change the conversation. Staff interviews confirmed that resident would unconsciously make-up stories and would believe that they were true. Staff said they would have to intervene and inform resident that everything would be fine so the residents emotional state would stabilize. LPA attempted to speak with the LTCO but was unable. Interview with outside source said they had no concerns with the staff, or the care being provided by the facility to their loved one. A review of records revealed that resident does have a diagnosis of loss of intellectual functioning. Their primary diagnosis on their Physician’s Report (LIC602), per WebMD’s definition, describes it as damage or disease that affects the brain that leads to an altered mental state, leaving a person confused and not acting like oneself. Their LIC602 does confirm that resident is confused and at times may not be able to follow instructions. R1 does not have the capacity to provide themselves self-care. Per their mental cognition, the resident is non-ambulatory. The resident care notes shows that the resident is in need of ADL assistance with preparing items for them and standby assist. They also require reminders. A review of incident reports (IR) revealed that resident does have a history of falls. On 4/15/24, resident was found confused on the floor and staff initiated emergency response. Resident was taken to the hospital and treated. Residents responsible party (RP) and primary care physician (PCP) were notified. Another IR, dated 01/10/2024, revealed that R1 had fallen, and emergency response was initiated and R1 was taken to the hospital to be treated. This incident caused R1 to fracture their left wrist. R1’s PCP and RP were notified of the incident. According to hospital notes, R1 had old, healed fractures to the wrist and swelling to the right knee. Their mental cognition raced from topic to topic and very disjointed thinking. R1 does use a walker and hospital staff would need to follow them closely with a wheelchair.

Based on the Department’s investigation of the above-mentioned allegation and the evidence obtained during staff, resident and outside source interviews, records reviewed, and LPA observations, there is insufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegation is deemed to be unsubstantiated.

The report was discussed, and an exit interview was conducted with Executive Director Jay Agustine. A copy of this report along with Licensee/Appeal Rights (LIC9058 3/22) were provided to Executive Director Agustine at the conclusion of the visit. The signature below confirms the receipt of these documents.

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) -34-3976
LICENSING EVALUATOR NAME: Carmen Lopez	TELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024

LIC9099 (FAS) - (06/04)

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