374602972-3-26-2025-08-AS-RCLK-DFAPU7-20250331113704

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374602972
Report Date: 03/26/2025
Date Signed: 03/26/2025 01:22:59 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
02/24/2025 and conducted by Evaluator Ramon Serrano

COMPLAINT CONTROL NUMBER: 08-AS-20250224084404

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: 64	DATE:	03/26/2025
		UNANNOUNCED	TIME BEGAN:	09:39 AM
MET WITH:	Maria Shetler		TIME COMPLETED:	01:38 PM

ALLEGATION(S):

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Unlawful Eviction

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced complaint visit to deliver complaint investigation findings. LPA introduced himself and stated the purpose of the visit with Executive Director Maria Shetler.

The Department’s investigation consisted of interviews with staff, outside sources and review of records.

It was alleged that Resident 1 (R1) was unlawfully evicted. It was reported that on February 20, 2025 R1 was being combative with staff and residents. Facility staff advised R1's responsible party (RP) that they would need to either send R1 to the hospital or pick R1 up from the facility. It was reported that the facility advised R1's RP as well as an outside source that R1 could not return to the facility until they "figured something out" because it was not safe for other residents and staff.

(Continued on LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Robyn Clark	TELEPHONE: (619) 767-2312
LICENSING EVALUATOR NAME: Ramon Serrano	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 03/26/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2025

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 3

Control Number 08-AS-20250224084404

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: 03/26/2025

NARRATIVE

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Records review of R1's Physician's Report dated April 30, 2024 revealed a primary diagnosis of Aortic Atherosclerosis, CHF, GERD and Dementia. R1 is noted to have aggressive, wandering and sun downing behavior and is in "fair" physical health. CCLD received three incident reports involving R1 on February 21, 2025. On February 17, 2025 it was reported that R1 was being aggressive towards another resident. On February 19, 2025 it was reported that R1 hit a caregiver with a hanger. On February 20, 2025 it was reported that R1 was being aggressive with both staff and residents.

LPA interviewed Outside Agency (OA) who stated that they work closely with both R1 and the facility on a regular basis. OA stated that on February 20, 2025 they received correspondence from the facility stating that R1 was being combative once again with residents and staff. The facility informed R1's RP that R1 could not return to the facility until "something was figured out." OA stated that R1 has resided at the facility for almost a year and has a history of being aggressive and combative with facility staff and residents. OA stated that in the past R1's RP has been an obstacle to R1 fully acclimating in the facility. OA stated that R1's RP would regularly sign out R1 from the facility and keep R1 at their home for several days before returning R1 back to the facility. OA stated that this frequent disruption would result in R1 acting out aggressively towards both staff and residents. OA stated that they were in regular contact with the facility on and immediately after the February 20th incident. OA stated that within a few days of the incident R1's medications were re-evaluated and changed by the medical team. OA stated that R1 was never formally evicted or issued a 30 day notice to quit and returned to the facility a short time after they were sent out to the hospital. OA stated that as of today R1 is doing much better at the facility and new interventions were put in place for all of the residents in care. OA stated that they advised R1's RP and family that R1 needs to be "left alone" at the facility for 30-45 days so that R1 can get fully adjusted to their new medications.

LPA interviewed Outside Source (OS) who stated that R1 had an "episode" on February 20, 2025 due to their Dementia diagnosis. OS stated that R1 left the facility with a family member and R1 returned to the facility approximately 1-2 weeks after the incident. OS stated that R1 "got out of hand" on the date of the incident but they do not believe that the facility unlawfully evicted R1 or "threw R1 out" as a result of the incident. OS stated that an outside agency informed RP and R1's family that they needed to stop taking R1 from the facility so that R1 could get properly adjusted to their new medications as well as the staff and residents.

SUPERVISOR'S NAME: Robyn Clark	TELEPHONE: (619) 767-2312
LICENSING EVALUATOR NAME: Ramon Serrano	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 03/26/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2025

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20250224084404

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: 03/26/2025

NARRATIVE

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LPA interviewed Executive Director (ED) who stated that she has been asking R1's outside mental health and medical team to send R1 to an inpatient behavioral unit so that R1's medications could be "adjusted." ED stated that it was never stated that R1 was being evicted or could not return to the facility, they were simply asking for help with R1's behaviors. ED stated that they were advised by R1's outside agency team that if R1 acted out again to send R1 out on a "5150." ED questioned why R1 could not be sent to a Behavioral unit such as Alvarado Hospital since it would be less traumatic to R1. ED stated that on the date of the incident on February 20, 2025 R1's RP agreed to take R1 to their residence instead of sending R1 out on a 5150 hold. ED stated that R1's RP agreed to keep R1 until after the scheduled meeting they had planned with R1's outside agency medical team which included R1's medication re-evaluation. ED stated that R1 returned to the facility on March 7, 2025 with new medication orders and despite a few minor incidents R1 has adjusted well.

Based on interviews and records, while R1’s behaviors were indeed problematic for licensee, there does not exist a preponderance of evidence to prove that licensee unlawfully evicted R1. Therefore, the above allegation is deemed to be unsubstantiated.

The report was discussed, and an exit interview was conducted with Maria Shetler. A copy of this report along with Licensee/Appeal Rights (LIC9058 3/22) were provided to Maria Shetler at the conclusion of the visit. The signature below confirms the receipt of these documents.

SUPERVISOR'S NAME: Robyn Clark	TELEPHONE: (619) 767-2312
LICENSING EVALUATOR NAME: Ramon Serrano	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 03/26/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2025

LIC9099 (FAS) - (06/04)

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