374602930-8-7-2024-08-AS-SJAB-D8LM38-20240829091441

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374602930
Report Date: 08/07/2024
Date Signed: 08/07/2024 03:25:56 PM

Substantiated

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
09/17/2021 and conducted by Evaluator Iby Strong

PUBLIC

COMPLAINT CONTROL NUMBER: 08-AS-20210917102005

FACILITY NAME:	LUCIE'S SHADY REST		FACILITY NUMBER:	374602930
ADMINISTRATOR:	ZACHAY, GILBERT		FACILITY TYPE:	740
ADDRESS:	7142 BOBHIRD		TELEPHONE:	(619) 741-4460
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92119
CAPACITY:	6	CENSUS: 6	DATE:	08/07/2024
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Administrator Gilbert Zachay		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Facility not following COVID-19 Mitigation Plan

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Iby Strong conducted an unannounced complaint visit to deliver findings on the above-mentioned allegation. LPA met Administrator Gilbert Zachay and discussed the purpose of the visit.
- On September 17, 2021, Community Care Licensing (CCL) received a complaint alleging facility staff were not wearing face covering while providing residents care as defined in the facility’s COVID-19 Mitigation Plan. During investigation, the Department collected pertinent facility documentation and conducted interviews. According to facility’s COVID-19 Mitigation Plan signed on January 23, 2021, “All facility staff are wearing a face covering while on the premises”. According to interview with outside source multiple facility staff was observed not wearing their face coverings on multiple occassions. Additionally, during investigation LPA Tellez observed staff and visitors without face coverings.
-Based on interviews a preponderance of evidence exists to support the allegations. Deficiencies are being cited per California Code of Regulations, Title 22. An exit interview was conducted with Administrator Gilbert Zachay, to whom a copy of this report LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Iby Strong	TELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024

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-20210917102005

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: LUCIE'S SHADY REST	FACILITY NUMBER: 374602930
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/07/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/21/2024 Section Cited CCR 87468.7(a)(2)	1 2 3 4 5 6 7	87468.1 Personal Rights of Resident in all facilities: "(a)Residents in all residential care facilities for the enldery shall have all of the following personal rights: (2) To be according safe, healthful....accomodations. This requirement was not met as evidence by:	1 2 3 4 5 6 7	Licensee agrees to provide all staff with resident personal rights training by plan of correction date.
	8 9 10 11 12 13 14	Based on observations the licensee did not accord 6 of 6 residents the right to have a safe and healthful accomodations.	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 Jacob	TELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Iby Strong	TELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
09/17/2021 and conducted by Evaluator Iby Strong

COMPLAINT CONTROL NUMBER: 08-AS-20210917102005

FACILITY NAME:	LUCIE'S SHADY REST		FACILITY NUMBER:	374602930
ADMINISTRATOR:	ZACHAY, GILBERT		FACILITY TYPE:	740
ADDRESS:	7142 BOBHIRD		TELEPHONE:	(619) 741-4460
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92119
CAPACITY:	6	CENSUS:	DATE:	08/07/2024
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Administrator Gilbert Zachay		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Neglect resulting in resident sustaining a pressure injury while in care
Licensee did not meet residents' needs
Staff are not properly trained on resident transfers
Staff are unable to communicate with residents due to language barrier
Resident's bed in disrepair

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Iby Strong conducted an unannounced complaint visit to deliver findings on the above-mentioned allegations. LPA met Administrator Gilbert Zachay and discussed the purpose of the visit.

On September 17, 2021, Community Care Licensing (CCL) received a complaint alleging neglect resulting in resident sustaining a pressure injury while in care, licensee did not meet residents' needs, staff are not properly trained on resident transfers, staff are unable to communicate with residents due to language barrier and resident's bed in disrepair. During the investigation, the Department conducted interviews, and reviewed facility records.

According to the allegations Resident 1 (R1) developed a wound, with no known stage, due to staff not providing adequate care. Medical records reviewed for R1 revealed that R1 was receiving outside medical services since August 24, 2021. Records also revealed that R1 developed a Stage 2 pressure sore as of September 1, 2021.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Iby Strong	TELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 08-AS-20210917102005

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: LUCIE'S SHADY REST	FACILITY NUMBER: 374602930
	VISIT DATE: 08/07/2024

NARRATIVE

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Continued from LIC9099-A
Interview with outside medical provider revealed that R1 did not appear to be neglected by facility and was naturally declining. Records also revealed that R1 passed away as of September 4, 2021, due to disease progression.

It was also alleged that licensee did not meet the resident’s needs as the staff was not adequately feeding the resident. Based on records reviewed, R1 had a poor appetite and would rarely eat. Interview with outside source revealed R1 was naturally declining in health which results in poor appetite. Medical records reviewed corroborated that R1 had poor food and liquid intake between August 24, 2021, to September 4, 2021.

Additionally, it was alleged that staff were not appropriately trained to transfer residents to and from their bed. Records collected reviewed revealed all staff have beyond the forty hours of required training in assistance with activities of daily living and dementia care. Interview with outside source did not reveal any information to corroborate that staff are not properly trained. Interview with Administrator established that staff are trained as required.

It was also alleged that staff are unable to communicate with residents due to language barrier. Based on the Department’s interviews, there was no evidence to prove staff are unable to communicate with residents. Interview with outside source revealed that staff do speak English, though some speak it as their second language. Based on observations, LPA Strong was able to communicate with staff present on today’s date.

Lastly, it was alleged that R1’s hospital bed was not working, though no further details were provided. Based on records collected, R1’s bed was provided to resident by an outside medical provider. Interview with outside source revealed that if there were any issues with the bed, the bed would have been replaced. Interview with Administrator revealed that no beds have ever been left broken over a 24-hour period.

Based on the Departments interviews, and record reviews there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegations are unsubstantiated. An exit interview was conducted with Administrator to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Iby Strong	TELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024

LIC9099 (FAS) - (06/04)

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