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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374602972
Report Date: 08/31/2022
Date Signed: 08/31/2022 03:03:09 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
06/13/2022 and conducted by Evaluator Dang Nguyen
COMPLAINT CONTROL NUMBER: 08-AS-20220613161900
FACILITY NAME:PLAZA VILLAGE SENIOR LIVINGFACILITY NUMBER:
374602972
ADMINISTRATOR:SHETLER, MARIAFACILITY TYPE:
740
ADDRESS:950 L AVETELEPHONE:
(619) 474-4844
CITY:NATIONAL CITYSTATE: CAZIP CODE:
91950
CAPACITY:85CENSUS: 63DATE:
08/31/2022
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Executive Director Maria Shetler and Community Relations Director Zack ShetlerTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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-Licensee did not dispose of an injection needle as required.
-Licensee did not maintain the facility in good repair.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced subsequent visit to deliver findings regarding the above prior complaint allegations. LPA was welcomed by, identified himself, and discussed the purpose of the visit with Executive Director Maria Shetler and Community Relations Director Zack Shetler.

It was alleged that license did not dispose of a medication/injection needle according to regulatory requirement(s). It was also alleged that licensee did not maintain the facility in good repair, because one or more of the facility’s wall-mounted pull cords and pendant/necklace call buttons (both of which residents use to summon staff help) were not working, and because the facility’s main ice-maker machine and water dispenser machines had long been inoperable. CCLD’s investigation involved three unannounced tours/welfare checks of the facility between June 2022 and August 2022, plus signals testing of pull cords and pendant buttons in active circulation. The Department also interviewed multiple managers, direct care staff, and residents, and reviewed pertinent internal facility documents and third-party records. [CONTINUED ON LIC 9099-C, 1 of 3]
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022
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 7
Control Number 08-AS-20220613161900
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: PLAZA VILLAGE SENIOR LIVING
FACILITY NUMBER: 374602972
VISIT DATE: 08/31/2022
NARRATIVE
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[CONTINUED FROM LIC 9099]

Regarding the first allegation, there was evidence that incorrect disposal of a medication/injection needle led to an adverse, but preventable, incident. Interviews of 4 of 4 facility managers and an internal Accident/Incident Report revealed that on the morning of 06-02-2022, Staff #1 (S1) [see LIC811 Confidential Names List for a description of S1] was cleaning/wiping down a table in the facility’s dining room, when their hand was pierced by a loose needle on the table, necessitating S1 receiving basic first aid at the facility before undergoing blood testing at an off-site occupational medicine clinic contracted by the licensee. S1’s Work Status Activity Report from the health clinic listed their diagnosis as, “Exposure to body fluids by contaminated hypodermic needle stick.” Interviews of multiple direct care staff present that day (each was cross-referenced against facility’s June 2022 work schedule), further confirmed that the needle in question was a medicine/injection needle, and not a sewing needle. Regulation 87303 of the California Code of Regulations, Title 22, Division 6 requires that used medication needles to be disposed of in containers which are rigid, puncture resistant, leakproof, portable, and correctly labeled as either “biohazardous waste” or “sharps waste.” The needle which pierced S1’s hand was not disposed of in such a container, and its presence on a dining room table potentially threatened the health of residents in care. Staff interviews unanimously corroborated that facility policy/practice requires used medicine/injection needles to be discarded in a sharps-disposal container. LPA observed these purpose-made containers, made of a hard red plastic with a non-removable lid, present in the facility’s medication room during his site visits.

Regarding the second allegation, the investigation uncovered statistically significant technical problems regarding the facility’s pull cords and pendant buttons. Interviews of direct care staff and managers unanimously corroborated: a) When activated, both device types are supposed to transmit a silent signal to pager devices, indicating the name of the resident who needs help and their location, b) Every caregiver and medication technician carries a pager when on duty, and c) Every “Assisted Living” resident (i.e. someone without dementia living on either the 3rd and 4th floor) is automatically issued a pendant at time of move in, but the resident’s use of the pendant thereafter is optional. During a 06-21-2022 site visit, LPA conducted an audit/test of both device types. One-by-one, LPA activated 3 randomly selected pull cords from each of the facility’s 4 floors. LPA also tested the specific pull cord cited by the complainant in their allegation.

[CONTINUED ON LIC 9099-C, 2 of 3]
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 08-AS-20220613161900
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: PLAZA VILLAGE SENIOR LIVING
FACILITY NUMBER: 374602972
VISIT DATE: 08/31/2022
NARRATIVE
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[CONTINUED FROM LIC 9099-C, 1 of 3] One-by-one, with resident consent, LPA also tested 6 pendant buttons which were in circulation with current “Assisted Living” residents. (LPA attempted to expand the sample pool of pendants but found that two-thirds of the residents approached for this purpose reported they no longer used their pendant device.) Staff #2 (S2), a facility manager, held a pager device in their hands and stood beside LPA during the tests. During each instance that LPA suspected a signals transmission failure, S2 independently concurred with LPA’s assessment. Of the 13 pull cords tested, 4 failed to transmit a signal to the pager, representing a failure rate over 30%. Of the 6 pendants tested, 2 failed to transmit a signal to the pager, again representing a failure rate over 30%. (Device failure rates of over 30% illustrate a pattern of poor repair, rather than an isolated exception). S2 logged the failed pull cords/pendants on a writing pad, and told LPA that the facility’s maintenance staff followed up to repair the devices shortly after LPA’s visit. Interview of S2 and another manager revealed that prior to LPA’s 06-21-2022 audit, licensee had not yet developed a procedure to test the pull cord and pendant devices periodically/pre-emptively. On a separate day (i.e. 08-10-22), LPA interviewed “Assisted Living” residents about their pendants: 3 of 8 residents said they chose not to wear their pendant button, without stating a reason. Of the remaining 5 residents interviewed, 2 said they pushed their pendant call button in the past but stopped using it due to a loss of confidence that staff will respond to it.

According to manager interviews, several months before the timeframe of the complaint, the facility’s ice-maker machine stopped working and a replacement unit subsequently broke during transit. However, staff continued to buy bagged ice from a local grocery store and make it available to residents upon request. LPA consistently observed bag ice in the 1st floor kitchen area during his site visits. 6 of 8 Assisted Living residents interviewed said they made their own ice using the facility-provided freezers located on either the 3rd floor of 4th floor common-area kitchenette, 1 of 8 residents said they ask for ice from the 1st floor kitchen, and 1 of 8 residents declined to comment. According to manager interviews, several months before the timeframe of the complaint, licensee removed its rented/third-party wall-mounted water dispensers, replacing them with facility-purchased ones. However, the latter had trouble providing clean water, so staff quickly unplugged them and rendered them inoperable to protect resident health. During his site visit, LPA observed that the newer water dispensers were indeed unplugged, and drinking water was still available in pitchers in the dining room, medication room, and in smaller portable dispensers near elevator entrances. [CONTINUED ON LIC 9099-C, 3 of 3]
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 08-AS-20220613161900
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: PLAZA VILLAGE SENIOR LIVING
FACILITY NUMBER: 374602972
VISIT DATE: 08/31/2022
NARRATIVE
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[CONTINUED FROM LIC 9099-C, 2 of 3] 8 of 8 residents interviewed said that access to ice and drinking water was not a problem for them. Licensee ensured continued resident access to ice and water while some of the associated machines were down, enabling residents’ basic needs to be met (which is the Department’s concern). There is no regulation requiring licensee to specifically procure water or ice from a dispensing machine.

Based on interviews and records, the preponderance of evidence showed that on at least one day, licensee did not dispose of an injection needle as required, resulting in an adverse outcome. It also showed that while licensee indeed operated a “signal system” (as is required by regulation for a facility of this size), licensee did not maintain its components (i.e. pull cords and pendants) in a state of good repair. Both allegations are therefore substantiated. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D).

A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with the Shetlers, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 01/16) were provided.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 08-AS-20220613161900
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: PLAZA VILLAGE SENIOR LIVING
FACILITY NUMBER: 374602972
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/30/2022
Section Cited
CCR
87303(f)(2)
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87303 Maintenance and Operation: “(f)(2) Syringes and needles are [to be] disposed of in accordance with California Code of Regulations, Title 8, Section 5193…paraphrased in pertinent part: (4)…contaminated needles shall be placed in appropriate containers that shall be: a. Rigid, b. Puncture resistant, c. Leakproof…, d. Portable…, e. Labeled…” This requirement was not met, as evidenced by:
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The administrator said S1 was tested for bloodborne pathogens in June 2022 and will continue to be blood-tested monthly (via the occupational medicine clinic) through December 2022. The administrator agreed to coordinate retraining (led by a licensed professional) of all its staff who are authorized to pass medications. The training will cover bloodborne pathogens, solid waste requirements per 87303(f), infection control requirements per 87470, and procedures for coordinating with its third-party sharps-disposal vendor. Administrator agreed to E-mail the training sign-in sheet to LPA before the POC due date.
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Based on records and interviews, licensee did not dispose of a contaminated needle in a container meeting the requirements of California Code of Regulations, Title 8, Section 5193, resulting in S1 being stuck in the hand with a loose needle in the dining room. This posed a potential health risk to 66 of 66 residents in care.
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Type B
09/30/2022
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation: “(a) The facility shall be…safe…and in good repair at all times.” This requirement is not met as evidenced by:
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The administrator said in late June 2022, all pull cords and pendant buttons were tested and repaired/replaced as needed. Going forward, the administrator agreed to implement biannual preemptive signals testing of all facility pull cords and pendants in active circulation, and to develop an internal checklist form which allows future tests to be documented in writing. Administrator agreed to E-mail a template of the form to LPA before the POC due date.
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Based on interviews and LPA’s observations, licensee did not maintain its required signal system in good repair at all times. This posed a potential safety risk to 66 of 66 residents in care.
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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: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 7
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
06/13/2022 and conducted by Evaluator Dang Nguyen
COMPLAINT CONTROL NUMBER: 08-AS-20220613161900

FACILITY NAME:PLAZA VILLAGE SENIOR LIVINGFACILITY NUMBER:
374602972
ADMINISTRATOR:SHETLER, MARIAFACILITY TYPE:
740
ADDRESS:950 L AVETELEPHONE:
(619) 474-4844
CITY:NATIONAL CITYSTATE: CAZIP CODE:
91950
CAPACITY:85CENSUS: 63DATE:
08/31/2022
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Executive Director Maria Shetler and Community Relations Director Zack ShetlerTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Licensee did not store knives/scissors inaccessible to residents with dementia.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced subsequent visit to deliver a finding regarding the above prior complaint allegation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Maria Shetler and Community Relations Director Zack Shetler.

It was alleged that licensee did not provide residents a safe environment, principally because sharp cooking knives/scissors (located within the shared kitchen area of the facility’s 4th floor) were left unlocked and accessible to residents in care. CCLD’s investigation involved review of relevant medical records, multiple days of observation of the facility’s 4th floor, and interviews of the residents who live on the 4th floor, plus pertinent facility staff.

[CONTINUED ON LIC 9099]
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 08-AS-20220613161900
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: PLAZA VILLAGE SENIOR LIVING
FACILITY NUMBER: 374602972
VISIT DATE: 08/31/2022
NARRATIVE
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[CONTINUED FROM LIC 9099]

While LPA indeed observed a cooking knife accessible/unlocked within the shared kitchen area of the facility’s 4th floor, the investigation uncovered additional context showing that according to regulation, said knife was not a safety hazard to the specific residents in care who had access to it. According to Regulation 87705 of the California Code of Regulations, Title 22, Division 6, knives must only be stored inaccessible to residents diagnosed with dementia. At the time of the complaint allegation, there were 13 residents living on the 4th floor. Review of their LIC602 Physician’s Reports (and where applicable, additional physician’s notes) showed that 8 of these 13 residents were diagnosed with Mild Cognitive Impairment (MCI), but not dementia. The remaining 5 of 13 residents had no cognitive impairment diagnosis whatsoever, according to their physicians. Physicians for all 13 residents additionally affirmed that their patient had some basic safety awareness regarding potentially hazardous objects.

During his visits, LPA observed 4th floor residents competently preparing meals/snacks in the kitchen; LPA had no safety concerns about what he saw. The 4th floor residents all appeared calm, alert, oriented, and articulate. LPA privately interviewed 6 of the residents from this floor: each affirmed they do not have dementia, and each also affirmed that they can safely use cooking knives and scissors. None harbored safety concerns about any of their 4th floor peers having access to and/or using knives and scissors. Interviews of 3 of 3 direct care staff and 4 of 4 managers unanimously corroborated that none of the 4th floor residents have dementia, and that all can safely use knives and scissors. Staff interviews and LPA observations additionally illustrated that all residents who are diagnosed with dementia live exclusively in the facility’s secured memory care neighborhood, located on the 1st and 2nd floors behind a delayed-egress door. Residents living in this memory care neighborhood do not have independent access to the 4th floor.

Based on interviews and records, a preponderance of evidence does not exist to prove that the presence of an unlocked knife (or even scissors) on the facility’s 4th floor constitutes a hazard to the actual residents who can access it there. The allegation is therefore unsubstantiated. An exit interview was conducted with the Shetlers, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 7