374603125-2-23-2023-08-AS-DPOL-CPH2GL-20230228162319

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603125
Report Date: 02/23/2023
Date Signed: 02/23/2023 01:43:23 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
03/24/2022 and conducted by Evaluator Marisela Garcia-Centeno

COMPLAINT CONTROL NUMBER: 08-AS-20220324162817

FACILITY NAME:	RANCHO SANTA FE VILLA		FACILITY NUMBER:	374603125
ADMINISTRATOR:	BAHA, RAY CYRUS		FACILITY TYPE:	740
ADDRESS:	8292 RUN OF THE KNOLLS		TELEPHONE:	(858) 361-3322
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92127
CAPACITY:	6	CENSUS: 5	DATE:	02/23/2023
		UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Administrator, Cyrus Ray Baha		TIME COMPLETED:	11:20 AM

ALLEGATION(S):

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Staff restrained resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced visit to deliver investigative findings. LPA was greeted by Caregiver, Angelita Hernandez, to whom she identified herself. LPA met with Administrator, Ray Cyrus Baha, to whom she discussed the purpose of the visit.

The Department investigated the above listed complaint allegations. The investigation consisted of observations made during a tour of the facility, multiple interviews with staff and outside sources, and records review, including resident and facility records relevant to this investigation.

On March 24, 2022, Community Care Licensing (CCL) received a complaint alleging that staff restrained a resident. It was specifically alleged that a Resident (R1), [an LIC 811 Confidential Names List was provided to staff to identify (R1)] was observed sitting in their wheelchair with a gait belt wrapped around the resident and tied in the back.
(Continue at LIC9099C)

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023

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-20220324162817

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: RANCHO SANTA FE VILLA	FACILITY NUMBER: 374603125
	VISIT DATE: 02/23/2023

NARRATIVE

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(Continue from LIC9099)

R1 was observed attempting to get up but the gait belt restricted R1’s movements. It was further alleged that R1 was also observed laying in their hospital bed with large furniture items blocking their bed to prevent R1 from getting out of bed.

On March 30, 2022, during a tour of the facility, R1 was observed sitting in their wheelchair with a gait belt wrapped around their body tied in the back. Review of R1’s medical records indicated that R1 had a diagnosis of dementia and required assistance with activities of daily living (ADLs), medication management and transfers. Review of records indicated that R1 was non-ambulatory based on both their physical and mental condition. R1 had a history of falls and fractures prior to moving into the facility. During the visit, R1 was observed to be appropriately dressed and groomed with no observable signs of neglect or physical abuse. During interviews, staff acknowledged that R1 was routinely restrained by a tied gait belt while sitting in their wheelchair in an attempt to prevent falls. R1’s medical records indicated that on March 22, 2022, a hospice physician order was put in place that indicated “facility may use a seat belt like devise tied loosely in the back of the wheelchair for safety with facility staff supervision as needed when the patient is up in their wheelchair”. However, Title 22 regulations require licensees to submit individual exception requests for Community Care Licensing (CCL) to review and approve the use of “postural support” devices, including gait and/or seat belts. Facility staff did not submit an exception request with supportive documentation to verify the physician’s order for R1. During interviews, staff indicated they were not aware that they were required to request approval and obtain advance authorization from CCL for the use of these types of devices.

During the same visit conducted on March 30, 2022, another Resident (R2) [an LIC 811 Confidential Names List was provided to staff to identify the Resident (R2)] was observed lying in bed watching television. R2’s hospital bed was observed to be barricaded with large, heavy wooden chairs from where the half rails ended, up to the foot of the bed.

(Continue at LIC9099C)

SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20220324162817

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: RANCHO SANTA FE VILLA	FACILITY NUMBER: 374603125
	VISIT DATE: 02/23/2023

NARRATIVE

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(Continue from LIC9099C)

During interviews, outside sources stated they consistently observed the chairs leaning against R2’s bed during regular visits. Outside sources stated they assumed it was standard protocol for facility staff to use the large chairs to block resident movement, as they had also observed another resident’s (R1’s) bed in the same manner. Staff admitted during interviews that the chairs were used as “block off” devices to prevent residents from falling out of bed. Staff explained they were not aware this practice was considered to be restraint, which is a personal rights violation. Record reviews determined no specific fall prevention measures, such as fall mats, tab alarms, increased monitoring or other allowable interventions were documented on R1 or R2’s needs and services care plans.

The Department has investigated the allegation and has found that there was sufficient evidence to corroborate the allegation. Therefore, this allegation is deemed to be substantiated. A substantiated finding means the allegation is valid because the preponderance of the evidence standard has been met. A deficiency was cited per Title 22, Division 6, Chapter 8 of the California Code of Regulations and is listed on LIC 9099-D. A plan of corrections was developed with Administrator, Ray Cyrus Baha

An exit interview was conducted with Administrator, Baha, to whom a copy of this report and Licensee Appeal Rights (9058 01/16) were provided at the conclusion of the visit.

SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20220324162817

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: RANCHO SANTA FE VILLA	FACILITY NUMBER: 374603125
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/23/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/17/2023 Section Cited CCR 87468.1	1 2 3 4 5 6 7	87468.1 Personal(a)(3) Rights of Residents in All Facilities. (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: ...(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature,… not to be placed in any restraining device. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator will conduct additional training from an external third party provider on personal rights of residents and on postural supports. Administrator will submit documentation to CCL of the trainings conducted and certificates of completion received for all staff by POC. date of 3/17/2023.
	8 9 10 11 12 13 14	Based on observations, records review and staff interviews, licensee used restraining devices for 2 of 3 residents. This posed a potential personal rights risk to 2 of 3 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.

SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023

LIC9099 (FAS) - (06/04)

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