374603431-6-2-2023-08-AS-LTEZ-CTALVG-20230630090531

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603431
Report Date: 06/02/2023
Date Signed: 06/02/2023 02:43:12 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
03/09/2023 and conducted by Evaluator Rebecca A Ruiz

COMPLAINT CONTROL NUMBER: 08-AS-20230309135823

FACILITY NAME:	ACTIVCARE AT ROLLING HILLS RANCH		FACILITY NUMBER:	374603431
ADMINISTRATOR:	BONGHABIH N. SHEY		FACILITY TYPE:	740
ADDRESS:	850 DUNCAN RANCH ROAD		TELEPHONE:	(619) 482-8000
CITY:	CHULA VISTA	STATE: CA	ZIP CODE:	91914
CAPACITY:	60	CENSUS: 44	DATE:	06/02/2023
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Program Specialist Jessica Flores		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Licensee did not allow residents to have vistors

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced complaint visit to conduct follow-up and deliver findings regarding the above-mentioned allegation. LPA identified herself to, was greeted by, and explained the purpose of the visit to Program Specialist Jessica Flores.

During today's visit, LPA observed residents in care and interviewed residents and staff.

The Department's investigation consisted of interviews with residents, staff, and outside sources, records review, and a tour of the facility. It was alleged that the licensee did not allow residents to have visitors. Interviews revealed that Resident 1 (R1) would have visits from different family members on a daily basis. Interviews revealed that R1 would have episodes of agitation after visiting with family member 1 (F1).

Continued on LIC-9099-C page...

Substantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

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 5

Control Number 08-AS-20230309135823

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: ACTIVCARE AT ROLLING HILLS RANCH	FACILITY NUMBER: 374603431
	VISIT DATE: 06/02/2023

NARRATIVE

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Interviews revealed that during these visits, F1 would give R1 food that was a choking risk and would say things that would agitate R1. Interviews revealed that R1's responsible party did not want F1 to visit R1 at the facility and asked facility staff to deny F1 visitation. Interviews revealed that the Executive Director attempted to educate F1 regarding R1's dietary needs and agitation. Interviews revealed that in April 2023, F1 and their spouse visited R1 at the facility, became upset and started yelling at staff, and asked to leave by staff after verbally threatening facility staff. Interviews revealed that following the incident in April 2023, facility staff denied F1 visitation on at least one occasion. Interviews revealed that there is not a current restraining order or legal document denying F1 the ability to visit with R1.

The Department has investigated the above-mentioned allegation and based on interviews and record review, 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 Executive Director Beebee Smith via phone and Program Specialist Jessica Flores, to whom a copy of this report and the Licensee Appeal Rights (LIC9058 01/16) were provided via hard copy.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 08-AS-20230309135823

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: ACTIVCARE AT ROLLING HILLS RANCH	FACILITY NUMBER: 374603431
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/02/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/30/2023 Section Cited CCR 87468.1(a)(11)	1 2 3 4 5 6 7	Regulation 87468.1 Personal Rights of Resident in All Facilities (a)(11) to have their visitors... permitted to visit privately during reasonable hours and without prior notice... This requirement has not been met as evidenced by:	1 2 3 4 5 6 7	Executive Director stated they will schedule a vendor training on visitiaton for staff and will send a copy of the training sign in sheet to LPA by POC due date.
	8 9 10 11 12 13 14	Based on interviews and records review, the Licensee did not ensure R1 was permitted to have visitors. This poses a potential personal rights risk to 44 of 44 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: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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
03/09/2023 and conducted by Evaluator Rebecca A Ruiz

COMPLAINT CONTROL NUMBER: 08-AS-20230309135823

FACILITY NAME:	ACTIVCARE AT ROLLING HILLS RANCH		FACILITY NUMBER:	374603431
ADMINISTRATOR:	BONGHABIH N. SHEY		FACILITY TYPE:	740
ADDRESS:	850 DUNCAN RANCH ROAD		TELEPHONE:	(619) 482-8000
CITY:	CHULA VISTA	STATE: CA	ZIP CODE:	91914
CAPACITY:	60	CENSUS: 44	DATE:	06/02/2023
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Program Specialist Jessica Flores		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Staff did not allow residents to refuse medications
Meals did not meet residents’ preferences
Staff did not assist residents with meals

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced complaint visit to conduct follow-up and deliver findings regarding the above-mentioned allegations. LPA identified herself to, was greeted by, and explained the purpose of the visit to Program Specialist Jessica Flores.
During today's visit, LPA observed residents in care and interviewed residents and staff.

The Department's investigation consisted of interviews with residents, staff, and outside sources, records review, and a tour of the facility. It was alleged that staff did not assist residents with meals, meals did not meet residents’ preferences, and staff did not allow residents to refuse medications. Interviews and records review revealed that about 10 residents required some assistance with eating with varying levels of need, including R1 who had a physician order for a modified diet of thin liquids. Interviews revealed that staff would group residents who required assistance with feeding together during mealtime and roughly 8 staff members would assist residents during meals.
Continued on LIC9099-C page...

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 08-AS-20230309135823

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: ACTIVCARE AT ROLLING HILLS RANCH	FACILITY NUMBER: 374603431
	VISIT DATE: 06/02/2023

NARRATIVE

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Interviews revealed that residents and their families were asked about the resident’s food preferences when they moved in, and the resident’s physician determined any meal modifications. If a resident did not like a certain food, they would inform staff who would pass the information to kitchen staff to make changes to their preferred food list. Interviews revealed that there were options for residents during each mealtime if they did not like a certain food item. Interviews revealed that if a resident’s meal preferences did not meet the prescribed meal modifications, staff would work with the resident, their family, and their physician to come to an agreement on meal modifications that met the resident’s preferences. Interviews revealed that R1 had a meal preference that differed from their prescribed meal modification and would refuse to eat those meals. Interviews revealed that staff consulted R1’s responsible parties and R1’s physician to modify R1’s diet to ensure R1 ate the meals. Interviews revealed that R1’s responsible parties were aware of the modification to R1’s diet and they assisted R1 with eating during mealtimes almost every day.

Interviews revealed that there were a few residents who would refuse medication occasionally and staff were instructed to ask the resident to take their medication at least three times before notifying the nurse on staff who would attempt an additional time before noting medication refusal. Interviews revealed that if the resident had a habit of refusing medication on a regular basis, that resident’s responsible party and physician were notified. Interviews revealed that R1 would refuse medications more frequently when R1 first moved to the facility. Interviews revealed that whenever R1 would refuse medications, staff would contact R1’s responsible parties to come to the facility to persuade R1 to take the medications. Staff were informed to be direct with R1 and explain the medications to R1 which decreased the rate of R1 refusing medications. Interviews did not reveal any instances of R1, or any other residents being forced to take medications.

The Department has investigated the above-mentioned allegations and based on interviews and records review, the preponderance of the evidence has not been met, therefore, these allegations are deemed unsubstantiated.

An exit interview was conducted with Executive Director Beebee Smith via phone and Program Specialist Jessica Flores, to whom a copy of this report and the Licensee Appeal Rights (LIC9058 01/16) were provided via hard copy.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

LIC9099 (FAS) - (06/04)

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