374603447-3-30-2022-08-AS-DPOL-CCZUXC-20220330155804

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603447
Report Date: 03/30/2022
Date Signed: 03/30/2022 03:43:38 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/29/2021 and conducted by Evaluator Liliana Silveira

PUBLIC

COMPLAINT CONTROL NUMBER: 08-AS-20210429120130

FACILITY NAME:	ST. PANTELEIMON ELDERCARE		FACILITY NUMBER:	374603447
ADMINISTRATOR:	MIRIAM GAVRILKINA		FACILITY TYPE:	740
ADDRESS:	1537 TIBIDABO DRIVE		TELEPHONE:	(760) 294-2743
CITY:	ESCONDIDO	STATE: CA	ZIP CODE:	92027
CAPACITY:	6	CENSUS: 0	DATE:	03/30/2022
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Licensee Miriam Gavrilkina		TIME COMPLETED:	02:20 PM

ALLEGATION(S):

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Resident #1 caused Resident #2 an injury due to neglect.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Liliana Silveira conducted a complaint investigation visit to deliver findings for the above allegation. LPA Silveira met with Licensee Miriam Gavrilkina and shared the findings.

The Department’s investigation consisted of interviews, records review, and observations. On 04/22/21, it was alleged that resident #1 (R1), threw an object at resident #2 (R2), causing minor injuries. An interview with staff confirmed that R1 did throw objects at R2. Interviews with police officers indicated that injuries in the form of bruising were observed on R2, due to the impact from the objects. Records review indicated that R1 had a diagnosed condition that caused a behavioral disturbance and R2 is an elder individual on hospice care. Records review also revealed that R1’s needs required a higher level of care. At the time of the incident, there was only one staff on duty who had been working at the facility for approximately 4 weeks.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Liliana Silveira	TELEPHONE: (619) 314-0756
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022

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-20210429120130

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: ST. PANTELEIMON ELDERCARE	FACILITY NUMBER: 374603447
	VISIT DATE: 03/30/2022

NARRATIVE

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St. Panteleimon Eldercare is a residential care facility for the elderly, 65 years of age and up. The facility had an elder resident and accepted a new resident who was under the age of 65, which is allowed. However, the two residents were not compatible. The new resident’s Physician’s report indicated the resident had a diagnosed condition which led to some behavioral outbursts.

Based on the evidence obtained from the complaint investigation, the allegation that Resident #1 caused Resident #2 an injury due to neglect is found to be SUBSTANTIATED, as there is a preponderance of evidence to show that the allegation occurred. Pursuant to the California Code of Regulations, Title 22, Division 6, deficiency is being cited on the attached LIC 9099D. (continued on page 2)

An exit interview was conducted, plan of correction was reviewed and a copy of this report and Licensee's Rights (9058 01/16) were provided to Miriam Gavrilkina via email, whose read receipt email verifies that these documents have been received

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Liliana Silveira	TELEPHONE: (619) 314-0756
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 08-AS-20210429120130

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: ST. PANTELEIMON ELDERCARE	FACILITY NUMBER: 374603447
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/30/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/30/2022 Section Cited CCR 87455(c)(3)(A)	1 2 3 4 5 6 7	8745 Acceptance...Limitations (c) No resident shall be accepted...if any of the following apply: (3) The resident's primary need for care and supervision results from (A) An ongoing behavior, caused by a mental disorder, that would upset the general resident group...	1 2 3 4 5 6 7	POC cleared as evidenced by facility closure. The deficiency is corrected as of today's visit, as it was verified that there are no longer any residents in care.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not comply with Acceptance regulations for one (1) out of two (2) residents. This posed a potential health & safety risk to residents 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: Denise Powell	TELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Liliana Silveira	TELEPHONE: (619) 314-0756
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3