374602751-11-29-2022-08-AS-SJAB-CLNVZE-20221130155237

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374602751
Report Date: 11/29/2022
Date Signed: 11/29/2022 08:56:42 PM

Unsubstantiated

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
07/13/2021 and conducted by Evaluator Debbie Correia

COMPLAINT CONTROL NUMBER: 08-AS-20210713160118

FACILITY NAME:	DEL CERRO MANOR III		FACILITY NUMBER:	374602751
ADMINISTRATOR:	BARTH, BENJAMIN		FACILITY TYPE:	740
ADDRESS:	6655 CRAMPTON COURT		TELEPHONE:	(619) 713-5193
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92119
CAPACITY:	6	CENSUS: 6	DATE:	11/29/2022
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Caregiver Elda Acosta		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Resident was hit while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced visit to deliver investigative findings on the above listed complaint allegation. LPA Correia met with Caregiver .....to whom was explained the purpose for the visit.

The Department’s investigation consisted of staff, resident, and outside source interviews. The investigation also consisted of facility and resident records review.

It was alleged Resident1 (R1) was hit by a facility caregiver. A record review revealed R1 was admitted to the facility April 26, 2021, was 98 years old, non-ambulatory, and had a primary diagnosis of Syncope and Collapse, and several other secondary health conditions. Records also revealed at the time of admission R1 was recovering from a fall and was disoriented and confused due to several transfers from different hospitals and rehabilitation facilities.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie Correia	TELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2022

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-20210713160118

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: DEL CERRO MANOR III	FACILITY NUMBER: 374602751
	VISIT DATE: 11/29/2022

NARRATIVE

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Interviews with an Outside Sources (OS1) revealed in July 2021 R1 was diagnosed with a UTI and during a medical appointment R1 alleged a new staff member at the facility had slapped them. OS1 reported at that time R1's file had already notated R1 was displaying behaviors of being confused and/or disoriented. Facility records and staff interviews revealed there was no new staff members at the time of the allegation, records also revealed all staff members had worked at the facility prior to R1’s admission. Staff interviews all corroborated R1 was very confused and would often carry on conversations by herself, and would tell random stories. Interviews and record reviews also revealed no known knowledge or documentation of the incident occurring, and no history of any abuse by staff towards residents is care. Resident interviews revealed no incidents of abuse by facility staff. The interviews with the residents in care all provided positive feedback regarding the staff and facility.

Due to lack of corroborating evidence, the finding regarding the above allegation was established to be unsubstantiated. This finding means there is not a preponderance of evidence to prove that the alleged violation occurred.

LPA Correia conducted an exit interview with Caregiver Acosta will be provided a copy of the Complaint Investigation Report (LIC9099) and Licensee Rights (LIC9058 01-2016) and signature on this report acknowledges receipt of the documents.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie Correia	TELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022

LIC9099 (FAS) - (06/04)

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