<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374602832
Report Date: 10/01/2021
Date Signed: 10/01/2021 01:34:39 PM

Substantiated


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
10/23/2019 and conducted by Evaluator Laarni Santiago
COMPLAINT CONTROL NUMBER: 08-AS-20191023081644
FACILITY NAME:LA VIDA DEL MARFACILITY NUMBER:
374602832
ADMINISTRATOR:WEST, LAURAFACILITY TYPE:
740
ADDRESS:850 DEL MAR DOWNS RDTELEPHONE:
(858) 755-1224
CITY:SOLANA BEACHSTATE: CAZIP CODE:
92075
CAPACITY:130CENSUS: 113DATE:
10/01/2021
UNANNOUNCEDTIME BEGAN:
11:08 AM
MET WITH:Laura West, Executive DirectorTIME COMPLETED:
11:50 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff neglect resulted in a minor injury sustained from a fall
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA), Laarni Santiago conducted an unannounced visit to conclude the investigation and deliver findings. LPA stated the purpose of the visit and spoke with Laura West, Executive Director.

The findings rendered are based on an investigation conducted by the Department. The investigation included a review of facility and medical records, as well as interviews conducted with staff and outside sources.

It was alleged that the facility staff neglected to respond to Resident 1’s (R1) {See LIC 811 Confidential Names List to identify R1} private caregiver’s call for assistance which resulted in R1’s fall. Records and interviews revealed that R1 had a private caregiver from an outside agency. The private caregiver comes daily from 10:00AM to 3:30PM for care and companion to R1. Facility’s protocol for private caregivers is to notify facility staff when they are getting ready to leave and/or ask facility staff for assistance when they need help.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 318-5974
LICENSING EVALUATOR NAME: Laarni SantiagoTELEPHONE: (619) 318-5974
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2021
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-20191023081644
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 VIDA DEL MAR
FACILITY NUMBER: 374602832
VISIT DATE: 10/01/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Medical assessment indicate that R1 is non-ambulatory and requires a 2-person assist with transfers. On October 20th, 2019, interviews and records revealed that R1’s private caregiver called the
front desk around 2:45PM to request for assistance in R1’s room. Evidence obtained from staff interview confirms that the private caregiver reached out to the front desk to ask for assistance and advised that they will be leaving shortly. Front desk alerted facility staff that R1’s private caregiver is requesting for assistance. Around 3:00PM, another call was made to the front desk from the private caregiver to report that no staff have responded to the initial request. Another attempt was made by the Receptionist to alert staff that R1’s private caregiver is asking for assistance. Around 3:30PM, private caregiver came down to the front desk and notified Receptionist that they are off work and R1 is in her wheelchair. Private caregiver reported that none of the staff came in to check on R1 to provide them assistance. From on or about 2:45PM to 5:10PM, none of the facility staff checked in on R1 or responded to the multiple request made from the caregiver. Interview with Administrator revealed that staff do not typically check on residents with a private caregiver unless they request for assistance. Around 5:10PM, facility staff (S1 – See Confidential Names List on LIC 811) came in to check on R1 while making their rounds and was found on the floor in their room, next to their bed. An assessment was conducted on R1 and a bruise was observed on their right side of rib and lower leg, but no pain or fractures incurred from the fall.

Based on evidence obtained from interviews and record reviews, it was determined that the facility staff neglected to respond to R1’s private caregiver’s request for assistance. Although staff acknowledged that R1 is a 2-person assist, no response was received when multiple attempts were made to request for help, leaving R1 on their own after the private caregiver left. Therefore, the allegation is found to be substantiated. This finding means that the preponderance of the evidence standard has been met and the allegation is valid. Deficiency is cited in accordance with California Code of Regulations, Title 22, Division 6, Chapter 8 and noted on the attached LIC 9099-D.

An exit interview was conducted with Executive Director, and was provided a copy of this report and Licensee Appeal Rights, via electronic mail, after conclusion of the visit. An electronic receipt of confirmation was requested to be sent to LPA upon receipt of the documents.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 318-5974
LICENSING EVALUATOR NAME: Laarni SantiagoTELEPHONE: (619) 318-5974
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 08-AS-20191023081644
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 VIDA DEL MAR
FACILITY NUMBER: 374602832
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
10/02/2021
Section Cited
CCR
87705(c)(4)
1
2
3
4
5
6
7
Care of Persons with Dementia
There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal.
1
2
3
4
5
6
7
The facility revamped the communication protocols between private caregivers and facility staff soon after the incident took place. Proof of this training will be submitted to CCL on 10/08/2021.
8
9
10
11
12
13
14
This requirement is not met based on evidence by: Interviews and records revealed that staff failed to ensure that R1 had adequate staff to support their needs as noted in their care plan. This poses an immediate health and safety risk to 1 out of 112 residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Simon JacobTELEPHONE: (619) 318-5974
LICENSING EVALUATOR NAME: Laarni SantiagoTELEPHONE: (619) 318-5974
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
10/23/2019 and conducted by Evaluator Laarni Santiago
COMPLAINT CONTROL NUMBER: 08-AS-20191023081644

FACILITY NAME:LA VIDA DEL MARFACILITY NUMBER:
374602832
ADMINISTRATOR:WEST, LAURAFACILITY TYPE:
740
ADDRESS:850 DEL MAR DOWNS RDTELEPHONE:
(858) 755-1224
CITY:SOLANA BEACHSTATE: CAZIP CODE:
92075
CAPACITY:130CENSUS: 113DATE:
10/01/2021
UNANNOUNCEDTIME BEGAN:
11:08 AM
MET WITH:Laura West, Executive DirectorTIME COMPLETED:
11:50 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff handled resident roughly that resulted in bruising
Resident was left soiled for an extended period of time.
Facility staff failed to meet resident’s needs
Facility staff failed to safeguard resident’s personal belongings
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
It was alleged that R1 was observed with suspicious bruising located on the right upper chest, under the neck and right shoulder that appeared to have been due to R1 being handled roughly while under the care of facility staff. Medical records note that R1 was observed with a hematoma to right and left bicep during a visit from an outside agency on October 9th, 2019. On October 20th, 2019, R1 had an unwitnessed fall and sustained a bruise on their right-side rib and lower leg. On October 22nd, 2019, R1 was reportedly observed with a bruise on right lower shin. Evidence obtained from interviews and records note that R1 is taking blood thinner medication. Although these bruises were observed on R1 by the Department, staff and outside source, investigation did not yield any specific occurrences during which R1 was handled in a rough manner. Facility staff and private caregivers were trained on how to safely transfer R1 to prevent any bruises. Based on interviews, records and observations, there’s no corroborating evidence to suggest that R1 was roughly handled by facility staff. Therefore, the allegation is unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 318-5974
LICENSING EVALUATOR NAME: Laarni SantiagoTELEPHONE: (619) 318-5974
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 08-AS-20191023081644
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 VIDA DEL MAR
FACILITY NUMBER: 374602832
VISIT DATE: 10/01/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
It was alleged that R1 was left soiled for an extended period of time on October 20th, 2021. Interviews conducted with staff revealed that R1 was found in the room with soiled diaper. Medical records revealed that R1 has a bowel and bladder incontinence and she is dependent in all Activities of Daily Living (ADL) including toileting and incontinence care. Evidence obtained from interviews revealed that staff makes their round every two hours to check in on residents. A private caregiver to supervise R1 from 10:00 AM to 3:30PM and one of their duty is to provide incontinence care. On October 20th, 2021, R1’s private caregiver left the facility around 3:30 PM. Around 5:10PM, facility staff checked on R1 and found them on the floor with soiled diapers. Interview with outside source did not express having observed R1 with soiled diapers. Although it was claimed that R1 was observed with soiled diaper on one occasion, interviews conducted with other relevant individuals revealed that bi-hourly checks are conducted which includes incontinence care and there are no other concerns expressed regarding incontinence care.

It was alleged that facility failed to meet R1’s needs by not being provided adequate amount of liquids and food which led to weight loss. Interviews and records indicate that R1 required assistance with eating, and it was discovered that private caregiver and/or facility staff assists with their with meals by feeding. Evidence obtained from medical records revealed that R1 has a health condition that makes it difficult to swallow food or liquid. Furthermore, records show that R1 switched to pureed food and was provided Ensure when it became difficult to eat. The Department observed that R1 had water and Ensure kept in their refrigerator. Interviews conducted revealed that staff ensured R1 was provided water or other liquids such as Ensure. Interviews determined that during the day, private caregiver assisted with feeding R1; in the evening, it’s the facility staff. Interviews with staff reported that R1 did not have any issues with eating, and typically had an appetite. However, due to their health condition, their appetite have decreased which was indicative to their weight loss. Facility records documents when R1 was provided their meals whether its pureed, Ensure or chopped meals.

It was alleged that facility failed to safeguard resident’s belongings such as a CD player and CD’s belonging to R1. A review of R1's record did not include an inventory list to indicate any of the missing valuables (LIC 621) that were reported. Furthermore, staff were unaware of the missing items and advised that these were not reported as theft and loss. An interview with relevant person’s denied seeing a CD player or CD’s in R1’s room. This relevant person also denied that R1 owned those items. Furthermore, staff and outside source reported that R1 does not listen to music in their room. There is no evidence to support the allegation that facility failed to properly safeguard R1's personal belongings.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 318-5974
LICENSING EVALUATOR NAME: Laarni SantiagoTELEPHONE: (619) 318-5974
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 08-AS-20191023081644
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 VIDA DEL MAR
FACILITY NUMBER: 374602832
VISIT DATE: 10/01/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Based on interviews, observations and review of documentation, the findings were established to be unsubstantiated. This finding means although the allegations may have happened or could be valid, there is not a preponderance of evidence to prove that the alleged violations occurred.

An exit interview was conducted with Executive Director and was provided a copy of this report and Licensee Appeal Rights, via electronic mail, after conclusion of the visit. An electronic receipt of confirmation was requested to be sent to LPA upon receipt of the documents.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 318-5974
LICENSING EVALUATOR NAME: Laarni SantiagoTELEPHONE: (619) 318-5974
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 6