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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602643
Report Date: 11/02/2022
Date Signed: 11/02/2022 12:05:42 PM


Document Has Been Signed on 11/02/2022 12:05 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:MEADOW CREEK VILLAFACILITY NUMBER:
374602643
ADMINISTRATOR:KARPAL, VINODFACILITY TYPE:
740
ADDRESS:11443 MEADOW CREEK ROADTELEPHONE:
(619) 277-8868
CITY:EL CAJONSTATE: CAZIP CODE:
92020
CAPACITY:6CENSUS: 5DATE:
11/02/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Caregiver Monica Rizo and Licensee Vinod KarpalTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management visit to cite a deficiency identified during a complaint investigation. LPA was welcomed by, identified himself, and discusssed the purpose of the visit with Caregiver Monica Rizo. LPA then met with Licensee Vinod Karpal, who arrived later during the visit.

Facility records and staff interviews showed Resident #1 (R1) moved into the facility on 02-09-2020. R1 subsequently retained hospice care services. According to hospice agency documentation, between 03-25-2020 and 04-16-2020, licensee stopped R1’s hospice staff from entering the facility to inspect/care for R1, due to licensee’s concern about the wider community spread of COVID-19. CCLD reviewed its electronic database of prior-reported COVID-19 cases within licensed facilities, finding no indication that a Meadow Creek Villa staff or resident was COVID-positive either before or during said date range.

Licensee’s barring of entry to hospice staff, who are essential visitors, was inconsistent with CDSS’ guidance in Provider Information Notice (PIN) 20-04-ASC (published 03-05-2020) and PIN 20-07-ASC (published 03-13-2020). Licensee’s independent decision to stop hospice staff from entering the facility deprived R1 of third-party medical care and interfered with R1’s right to receive visitors. As a result, R1 missed 7 pre-scheduled Certified Nursing Assistant/Hospice Aide visits and 3 pre-scheduled licensed nurse visits.

A deficiency is cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Karpal, to whom a copy of this report, the LIC 809-D, and the Licensee/Appeal Rights (LIC9058 01/16) were provided.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/02/2022 12:05 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: MEADOW CREEK VILLA
FACILITY NUMBER: 374602643

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/02/2022
Section Cited

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87468.1 Personal Rights of Residents in All Facilities: “(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (11) To have their visitors…permitted to visit privately during reasonable hours and without prior notice…” This requirement is not met, as evidenced by:
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Based on records review, licensee did not uphold a resident’s right to have their essential visitors for 1 of 5 persons in care (R1), which posed a potential Personal Rights risk to persons 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: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2022
LIC809 (FAS) - (06/04)
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