374603494-8-31-2022-08-AS-SJAB-CHU26P-20220831170727

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603494
Report Date: 08/26/2022
Date Signed: 08/31/2022 04:54:15 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
07/13/2020 and conducted by Evaluator Debbie Correia

COMPLAINT CONTROL NUMBER: 08-AS-20200713120624

FACILITY NAME:	CASA DE VIDA SENIOR LIVING		FACILITY NUMBER:	374603494
ADMINISTRATOR:	LAURENE ATKINSON		FACILITY TYPE:	740
ADDRESS:	4633 DENWOOD ROAD		TELEPHONE:	(619) 697-9707
CITY:	LA MESA	STATE: CA	ZIP CODE:	91942
CAPACITY:	6	CENSUS: 4	DATE:	08/26/2022
		UNANNOUNCED	TIME BEGAN:	02:20 PM
MET WITH:	Licensee Laurene Atkinson		TIME COMPLETED:	03:35 PM

ALLEGATION(S):

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Staff did not provide a detailed explanation of additional services or accompanying itemization of charges, in the level of care increase letter to resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced visit to deliver investigative findings on the above listed complaint allegation. LPA was met and granted entry into the facility by Caregiver Shannon Conger to whom was explained the purpose for the visit. Licensee Laurene Atkinson arrived shortly later to join the visit.

The Department’s investigation consisted of outside source interviews, and a resident and facility record review.

It was alleged that the facility did not provide Resident1 (R1) a detailed list of services and their costs to explain the rate increase due to a change in level of care. A record review revealed R1 was admitted to the facility on May 24, 2018 with a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and a back injury. At the time of admission resident records revealed R1 was oriented and capable of managing their own finances, medical care, and medication management, however R1 was very weak and needed assistance with all activities that required ambulation. Additional resident records revealed, as of September 16, 2019, R1 had a decline in health and required assistance with money and medication management, incontinent care, and some assistance with feeding. A facility record review revealed at admission these additional services were included as basic services in the original monthly rate of $4,000 offered by the facility, except for incontinence care.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie Correia	TELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022

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 3

Control Number 08-AS-20200713120624

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: CASA DE VIDA SENIOR LIVING	FACILITY NUMBER: 374603494
	VISIT DATE: 08/26/2022

NARRATIVE

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Interviews with outside sources and a record review revealed R1 was provided a letter dated May 24, 2020 stating R1's monthly rate had increased to $5500 due to an increase in level of care. Further review of R1's records revealed the only additional service being provided outside the scope of services agreed upon at intake, per the Admission Agreement, was incontinence care. A review of the notification provided to R1 regarding the increased rate did not include a list of additional services, and their accompanying costs, that R1 required to meet their service needs. The resident record review revealed no documentation notifying R1 what additional services and their associated costs were provided to R1 to support the rate increase as stated in the Admission Agreement.

Based on LPA’s records review, and interviews conducted the above allegation is determined to be substantiated. A substantiated finding means the allegation is valid because the preponderance of the evidence standard has been met.

LPA Correia conducted an exit interview with Licensee Atkinson at the conclusion of the visit. Signature on this form confirms receipt of the reports (LIC9099), and Licensee/Appeal Rights (LIC9058 01-2016) and per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiency is being cited on the attached LIC 9099-D.

This is an amended version of the original report created on August 26, 2022.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie Correia	TELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 08-AS-20200713120624

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: CASA DE VIDA SENIOR LIVING	FACILITY NUMBER: 374603494
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/26/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/28/2022 Section Cited HSC 1569.657	1 2 3 4 5 6 7	Rate increase due to change in level of care;(a) ...licensee shall provide...written notice of the rate increase...at the new level of care. The notice shall include a detailed explanation of...services to be provided at the new level of care and...itemization of the charges.	1 2 3 4 5 6 7	Licensee agreed to attend, along with facility staff, a CCL approved vendorized training course that covers regulations on resident and faciltiy record requirements. Licensee will provide proof of completion by POC due date.
	8 9 10 11 12 13 14	Based on a record review and interviews the licensee did not provide a written notice of an itemized list of additional services and their accompanying cost to 1 out of 3 residents. This posed a potential personal rights risk to 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: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie Correia	TELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3