374603478-6-17-2022-08-AS-LTEZ-CFVNVM-20220630104811

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603478
Report Date: 06/17/2022
Date Signed: 06/17/2022 02:55:44 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,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/19/2021 and conducted by Evaluator Sabel Martinez

COMPLAINT CONTROL NUMBER: 08-AS-20211019114731

FACILITY NAME:	CHAMPINE MANOR		FACILITY NUMBER:	374603478
ADMINISTRATOR:	SRBIJANKA ZIVKU		FACILITY TYPE:	740
ADDRESS:	1725 TOBACCO ROAD		TELEPHONE:	(760) 747-3878
CITY:	ESCONDIDO	STATE: CA	ZIP CODE:	92026
CAPACITY:	6	CENSUS: 6	DATE:	06/17/2022
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Administrator, Virna Austria		TIME COMPLETED:	03:10 PM

ALLEGATION(S):

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Facility does not have an adequate supply of food
Licensee did not provide general hygiene items
Staff did not provide incontinence care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sabel Martinez, conducted an unannounced complaint visit regarding the above mentioned allegations. The LPA was greeted by Administrator, Virna Austria, identified himself, and was invited into the facility. During today's visit the LPA reviewed records, conducted interviews, and delivered findings.

Throughout the investigation, the LPA toured the facility, reviewed staff and resident records, and conducted interviews with residents, staff, and outside sources.

It was alleged the facility did not have an adequate supply of food. An interview with an outside source revealed that on one occasion, due to a misunderstanding in communication, all the supplies were stored in a different facility. This outside source was able to retrieve the supplies from the facility. Interviews with additional outside sources did not reveal concerns of a lack of food and confirmed the facility has had enough food to meet the residents’ needs and requests.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 380-3797
LICENSING EVALUATOR NAME: Sabel Martinez	TELEPHONE: (619) 755-7595
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2022

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-20211019114731

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: CHAMPINE MANOR	FACILITY NUMBER: 374603478
	VISIT DATE: 06/17/2022

NARRATIVE

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Interviews with residents confirmed the facility has had and has provided and adequate amount of food to the residents. During multiple tours of the facility, the LPA witnessed the facility had enough food supplies to meet the residents' needs.

It was alleged the licensee did not provide general hygiene items. Interviews with staff and outside sources confirmed the facility has had enough hygiene supplies to meet the residents’ needs. Outside sources confirmed some of the facility's supplies are provided by outside agencies. One resident did state the facility lacked body soap, but this concern was never addressed with staff, nor the Licensee. During multiple tours of the facility, the LPA witnessed the facility had enough hygiene supplies to meet the residents needs.

It was alleged staff did not provide incontinence care. Interviews with multiple outside sources, who conducted regular visits to the facility, did not reveal any concerns regarding the facility not providing incontinence care, nor residents reporting a lack of incontinence care. Interviews with staff corroborated incontinence care was provided in a timely manner, and as needed to meet the residents needs.

Although the allegations may have happened, there is not a preponderance of evidence to prove the alleged violations did occur, therefore, the allegations are unsubstantiated.

An exit interview was conducted with Administrator, Virna Austria, to whom a copy of this report and Licensee's Rights (LIC 9058 01/16) were provided to.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 380-3797
LICENSING EVALUATOR NAME: Sabel Martinez	TELEPHONE: (619) 755-7595
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2022

LIC9099 (FAS) - (06/04)

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