374603431-11-6-2023-08-AS-IESA-CY49NM-20231130223124

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603431
Report Date: 11/06/2023
Date Signed: 11/06/2023 03:16:44 PM

Unsubstantiated

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
01/04/2021 and conducted by Evaluator Becky Kennedy

COMPLAINT CONTROL NUMBER: 08-AS-20210104092711

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: 41	DATE:	11/06/2023
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Karen Pultorak		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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A lack of supervision resulted in a resident sustaining a fracture while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst Becky Kennedy concluded the investigation which began on 3/16/2021. LPA Kennedy made an unannounced visit to the above facility today and was greeted by Karen Pultorak, Program Director. LPA advised Program DSirector Pultorak of the reason for today's visit and delivered the investigation findings on the above allegation.
Investigation consisted of interviews with residents, staff, outside sources, record review, and tour of the interior and exterior facility. It was alleged that a lack of supervision resulted Resident 1 (R1) falling and sustaining a fracture.
Investigation revealed, through records review, interviews with facility and hospital staff, and R1, that R1 was found on their bedroom floor on 12-31-20. R1 sustained a femoral neck fracture.
Prior to the 12-31-20 incident, falling was concern for R1. Although R1 was able to get from their bed to the bathroom with the aid of a walker, to insure R1’s safety, R1 was supposed to use the call button so care staff could assist R1. On the night of R1’s fall, R1 did not call for assistance. R1 reported that they “fell out of bed.”

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Icela Estrada	TELEPHONE: (619) 688-6866
LICENSING EVALUATOR NAME: Becky Kennedy	TELEPHONE: 619-672-5843
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023

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-20210104092711

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: ACTIVCARE AT ROLLING HILLS RANCH	FACILITY NUMBER: 374603431
	VISIT DATE: 11/06/2023

NARRATIVE

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R1 received a care and toileting check every two hours when appropriate care is provided. Documents reviewed confirm that R1 received regular care/toileting check less than two hours prior to the fall. R1 was discovered on the floor during a regular a check. After the fall, facility staff assessed and monitored R1 and sent R1 to the hospital for additional treatment.

Based on interviews and the review of documents, it was determined that R1’s fall was not due to a lack of supervision and the finding is Unsubstantiated. An exit interview was conducted and a copy of this report, and appeal rights were given to Karen Pultorak.

SUPERVISOR'S NAME: Icela Estrada	TELEPHONE: (619) 688-6866
LICENSING EVALUATOR NAME: Becky Kennedy	TELEPHONE: 619-672-5843
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023

LIC9099 (FAS) - (06/04)

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