374603323-7-29-2024-08-AS-JLOT-D7PQ6F-20240731115329

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603323
Report Date: 07/29/2024
Date Signed: 07/29/2024 10:19:39 AM

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
12/21/2023 and conducted by Evaluator Rebecca A Ruiz

COMPLAINT CONTROL NUMBER: 08-AS-20231221162314

FACILITY NAME:	BARON'S PRESIDIO UNIVERSITY CITY		FACILITY NUMBER:	374603323
ADMINISTRATOR:	NARMINA MAMEDOVA		FACILITY TYPE:	740
ADDRESS:	6860 CONDON DRIVE		TELEPHONE:	(858) 558-4772
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92122
CAPACITY:	6	CENSUS: 6	DATE:	07/29/2024
		UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Caregiver Esther		TIME COMPLETED:	10:20 AM

ALLEGATION(S):

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Staff hit resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegation. LPA identified herself to, was greeted by, and explained the purpose of the visit to Caregiver Esther Villar. LPA spoke with Licensee Angie Norton via telephone during the visit.

The Department’s investigation consisted of interviews with staff, residents, and outside sources, record review, and a tour of the facility. It was alleged that Staff 1 (S1) hit Resident 1 (R1). Review of R1’s physician’s report and assessment documents revealed that R1 had a diagnosis of major cognitive impairment and was receiving care from an outside care provider. Interviews with staff and outside sources revealed that R1 had a history of becoming aggressive and combative during personal care, however, R1’s assessment records did not indicate that R1 had any aggression or inappropriate behaviors.

Continued on LIC9099-C page...

Substantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024

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-20231221162314

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: BARON'S PRESIDIO UNIVERSITY CITY	FACILITY NUMBER: 374603323
	VISIT DATE: 07/29/2024

NARRATIVE

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Interviews with staff and outside sources revealed that on 12/19/2023, an outside care provider was providing personal care services to R1 when R1 became aggressive. Statements made by outside sources and staff revealed that S1 entered R1’s room to assist the outside care provider. R1 remained agitated and attempted to hit S1 but did not make physical contact with S1. Outside sources revealed that S1 hit the right side of R1’s face with S1’s hand following R1’s attempt to hit S1. Interviews with S1 stated that S1 was attempting to grab R1’s hands to prevent R1 from punching or hitting when S1’s hand accidentally hit R1’s face. Interviews with S1 and outside sources made conflicting statements regarding the details of the incident, however both parties agreed that S1’s hand made physical contact with R1’s face during personal care on 12/19/2023. Interviews with staff and outside sources revealed that R1 did not sustain any injuries or physical marks following the incident on 12/19/2023.

The Department has investigated the above-mentioned allegation and based on interviews, the preponderance of the evidence has been met, therefore, this allegation is deemed substantiated. The following deficiency is cited per CA Code of Regulations Title 22 and noted on the attached LIC9099-D page.

An exit interview was conducted with Licensee Angie Norton via telephone and Caregiver Esther Villar, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20231221162314

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: BARON'S PRESIDIO UNIVERSITY CITY	FACILITY NUMBER: 374603323
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/29/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/26/2024 Section Cited CCR 87468.1(a)(1)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a) Residents… shall have all of the following personal rights: (1) to be accorded dignity with their personal relationships with staff… This requirement has not been met as evidenced by:	1 2 3 4 5 6 7	Norton stated that the staff member is no longer working at the facility. Staff will receive vendor training on personal rights and will submit certificates of completion to the Department by POC due date of 8/26/2024.
	8 9 10 11 12 13 14	Based on interviews, the Licensee did not ensure that Resident 1 was accorded with dignity when S1 hit R1 during personal care. This poses a potential personal rights risk to 6 of 6 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.

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024

LIC9099 (FAS) - (06/04)

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