<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603478
Report Date: 10/29/2020
Date Signed: 10/29/2020 04:09:26 PM



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
03/17/2020 and conducted by Evaluator Adam Hamer
COMPLAINT CONTROL NUMBER: 08-AS-20200317102259
FACILITY NAME:CHAMPINE MANORFACILITY NUMBER:
374603478
ADMINISTRATOR:SRBIJANKA ZIVKUFACILITY TYPE:
740
ADDRESS:1725 TOBACCO ROADTELEPHONE:
(760) 747-3878
CITY:ESCONDIDOSTATE: CAZIP CODE:
92026
CAPACITY:6CENSUS: 5DATE:
10/29/2020
UNANNOUNCEDTIME BEGAN:
03:55 PM
MET WITH:Maria Aguilar, House ManagerTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility did not allow hospice nurse to visit resident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Adam Hamer conducted an unannounced complaint investigation tele-visit via FaceTime due to COVID-19. LPA identified himself, met with Maria Aguilar and discussed the purpose of the tele-visit, which was to deliver findings for the above allegation.

The Department’s investigation included, but was not limited to, interviews with staff and outside sources. Facility records and outside source records were also obtained by the Department and reviewed for pertinent evidence.

The Department received a complaint on March 17, 2020 that the facility did not allow a hospice nurse to visit a resident. The evidence gathered during the investigation revealed that a resident (R1) (See Confidential Names List on LIC 811) was receiving hospice care at the time when visitor restrictions began to be implemented at the facility in March 2020 due to COVID-19. The Department’s interviews with outside sources and records review revealed that, although home health visits were restricted, R1 continued to receive medical visits by hospice nurses from March 2020 through October 2020. The Department’s interview with the licensee and facility staff also revealed that the facility never restricted medical visits or hospice nurse visits for any residents at any time throughout this period.

Based on the evidence obtained from the complaint investigation, this allegation that the facility did not allow hospice nurse to visit resident is UNSUBSTANTIATED, meaning that there is not a preponderance of the evidence to find that the allegation is true.

An exit interview was conducted with Ms. Aguilar, a List of Confidential Names and a copy of this report and Licensee's Rights (9058 01/16) were emailed to the licensee. An email read receipt confirmation confirms receipt of these documents.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Tony GirolamiTELEPHONE: (619) 767-2312
LICENSING EVALUATOR NAME: Adam HamerTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2020
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 2