374602972-2-7-2024-08-AS-LTEZ-D2X4PP-20240229181704

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374602972
Report Date: 02/07/2024
Date Signed: 02/07/2024 01:39:16 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
12/01/2022 and conducted by Evaluator Renita Hall

COMPLAINT CONTROL NUMBER: 08-AS-20221201153950

FACILITY NAME:	PLAZA VILLAGE SENIOR LIVING		FACILITY NUMBER:	374602972
ADMINISTRATOR:	SHETLER, MARIA		FACILITY TYPE:	740
ADDRESS:	950 L AVE		TELEPHONE:	(619) 474-4844
CITY:	NATIONAL CITY	STATE: CA	ZIP CODE:	91950
CAPACITY:	85	CENSUS: 62	DATE:	02/07/2024
		UNANNOUNCED	TIME BEGAN:	01:22 PM
MET WITH:	Maria Shetler, Administrator		TIME COMPLETED:	01:40 PM

ALLEGATION(S):

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Resident sustained unexplained injuries while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Renita Hall conducted an unannounced visit to deliver findings. LPA was allowed entry by Maria Shetler, Administrator. LPA identified herself and disclosed the purpose of the visit and elements of the findings to the Administrator.

The department received a complaint that the resident sustained unexplained injuries while in care. The investigation included a facility tour, interviews with staff and outside sources, and a records review.

On 12/01/22, Resident 1 (R1) with underlying dementia and reported history of chronic interstitial lung disease was transported from the Day Program to the Hospital due to complaining of abdomen pain and pain in the foot. The day program contacted the family members and Plaza Village Senior Living to report the event.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Renita Hall	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2024

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-20221201153950

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: PLAZA VILLAGE SENIOR LIVING	FACILITY NUMBER: 374602972
	VISIT DATE: 02/07/2024

NARRATIVE

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R1 was seen in the emergency room by the attending physician and diagnosed R1 with Cellulitis, unspecified cellulitis site, and scabies, R1 had already been receiving Keflex at Plaza Village Senior Center. R1 was treated with IV antibiotics and treatment was discussed with the family members, and discharged with hospice care.

On 12/09/22 at 1600 hours R1 passed away. The primary care physician certified the cause of death was from cardiorespiratory failure, sepsis, and cellulitis. There is not enough information to support the allegation of Neglect/Lack of Care and Supervision regarding R1s sustaining multiple wounds while in care at the facility. R1 was provided medical care by the hospice nurse to treat their wounds. At the same time, caregivers attended to R1's daily needs and communicated any concerns or changes to hospice staff. Therefore, the allegation that the Resident sustained unexplained injuries while in care is unsubstantiated. An unsubstantiated finding means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

An exit interview was conducted; a copy of this report along with Licensee Appeal Rights LIC 9058 (REV 3/22) was provided to the Administrator and her signature confirms receipt of these documents.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Renita Hall	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2024

LIC9099 (FAS) - (06/04)

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