374603402-1-20-2023-08-AS-JRAE-CNM3PV-20230131172610

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603402
Report Date: 01/20/2023
Date Signed: 01/20/2023 12:51:18 PM

Unsubstantiated

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
01/09/2023 and conducted by Evaluator Ramon Serrano

COMPLAINT CONTROL NUMBER: 08-AS-20230109181432

FACILITY NAME:	FREDERICKA MANOR		FACILITY NUMBER:	374603402
ADMINISTRATOR:	CRAIG SUMNER		FACILITY TYPE:	740
ADDRESS:	183 THIRD AVENUE		TELEPHONE:	(619) 205-4100
CITY:	CHULA VISTA	STATE: CA	ZIP CODE:	91910
CAPACITY:	560	CENSUS: 251	DATE:	01/20/2023
		UNANNOUNCED	TIME BEGAN:	12:18 PM
MET WITH:	Jolene Hall		TIME COMPLETED:	12:59 PM

ALLEGATION(S):

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Facility did not safeguard resident's belonging

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced complaint visit to deliver findings on the above allegation. LPA met with Executive Assistant Jolene Hall and we discussed the purpose of the visit and elements of the complaint.

Community Care Licensing (CCL) has investigated the above allegation. The investigation consisted of LPA interviews with staff and resident and records review.

In response to the allegation, it was alleged that resident's belongings were not safeguarded (R1) [an LIC 811 Confidential Names List was provided to the facility representative to identify the resident.] Staff interviews revealed on January 1, 2023 R1 had extensive flooding in their room due to a toilet issue. Several staff members assisted with the toilet repair and clean-up in R1's room. These same staff members stated that they were unaware of a missing ring at the time of the flooding incident. Interview with R1 revealed R1 has resided at the facility for over one year.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Ramon Serrano	TELEPHONE: (619) 458-2583
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

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-20230109181432

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: FREDERICKA MANOR	FACILITY NUMBER: 374603402
	VISIT DATE: 01/20/2023

NARRATIVE

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R1 stated that on January 1, 2023 they had a flooding accident in their room due to a broken toilet. R1 stated that a few days after the incident R1 noticed that their wedding ring was missing. R1 stated that due to recent weight loss their wedding ring was very loose on their finger and would often slip off. R1 stated that several days after the flooding incident R1 advised the facility that their wedding ring was missing. R1 stated that facility staff immediately came to their aid and began searching for the missing ring. R1 further stated that they do not place any blame on the facility or facility staff since R1 is not sure when or where they lost their ring.

Interview with Executive Director revealed on January 4, 2023, R1 notified facility staff that their wedding ring was missing. R1 advised staff that there wedding ring had become very loose on their hand but they continued to wear it for sentimental reasons. R1 advised staff that they had the ring on their hand as of January 1, 2023. On January 1, 2023 R1 broke their toilet and water was starting to overflow. Facility staff went to R1's unit to help with overflowing water and install new toilet. On January 4, 2023 R1 noticed their wedding ring was no longer on their finger. R1 advised staff that the ring might have been lost in the commotion when the toilet broke. Facility staff searched R1's unit as well as the library, dining room and all common areas of the building but the ring was not located.

Based upon the foregoing, the above listed allegation is unsubstantiated. This finding means that the preponderance of the evidence standard has not been met and the allegation is invalid.

An exit interview was conducted with Jolene Hall and a copy of this report and Licensee/Appeal Rights (LIC9058, 3/22) were provided to Jolene Hall whose signature below confirms receipt of documents.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Ramon Serrano	TELEPHONE: (619) 458-2583
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

LIC9099 (FAS) - (06/04)

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