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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603513
Report Date: 09/26/2024
Date Signed: 09/26/2024 11:59:49 AM

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
12/02/2020 and conducted by Evaluator Renita Hall
COMPLAINT CONTROL NUMBER: 08-AS-20201202155827
FACILITY NAME:PARKWAY GARDENS RETIREMENT CARE HOMEFACILITY NUMBER:
374603513
ADMINISTRATOR:CARMINDA RAMIREZFACILITY TYPE:
740
ADDRESS:660 VAN HOUTEN AVETELEPHONE:
(619) 444-2729
CITY:EL CAJONSTATE: CAZIP CODE:
92020
CAPACITY:15CENSUS: 9DATE:
09/26/2024
UNANNOUNCEDTIME BEGAN:
11:31 AM
MET WITH:Art Vinarao, CaregiverTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Questionable deaths
Staff mismanaged residents' medications
Staff failed to meet the residents' needs
Staff unable to communicate with residents due to a language barrier.
Untrained staff
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Renita Hall, conducted an unannounced visit to deliver findings regarding the above-mentioned allegations LPA was allowed entry by Art Vinarao,Caregiver. LPA identified herself and disclosed the purpose of the visit and elements of the findings with the Caregiver.

The Department’s investigation consisted of interviews with staff, residents, outside sources, a review of records, and a tour of the facility. It was alleged that neglect by facility staff resulted in the questionable deaths of Residents #1-2 (R1-R2). A review of records revealed R1 was non-ambulatory and required assistance with toileting, bathing, dressing, feeding, and incontinence care. R1 was confused/disoriented but was able to communicate their needs. R1 began receiving hospice services from a hospice agency on September 1, 2020. Interviews with staff indicated staff checked on R1 approximately every two hours and assisted R1 with repositioning and incontinence care. R1 was prescribed oxygen and morphine to aid in comfort care.

{Continued on 9099C}
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Renita Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
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 5
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
12/02/2020 and conducted by Evaluator Renita Hall
COMPLAINT CONTROL NUMBER: 08-AS-20201202155827

FACILITY NAME:PARKWAY GARDENS RETIREMENT CARE HOMEFACILITY NUMBER:
374603513
ADMINISTRATOR:CARMINDA RAMIREZFACILITY TYPE:
740
ADDRESS:660 VAN HOUTEN AVETELEPHONE:
(619) 444-2729
CITY:EL CAJONSTATE: CAZIP CODE:
92020
CAPACITY:15CENSUS: 9DATE:
09/26/2024
UNANNOUNCEDTIME BEGAN:
11:31 AM
MET WITH:Art Vinarao, CaregiverTIME COMPLETED:
12:00 PM
ALLEGATION(S):
1
2
3
4
5
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7
8
9
Uncleared adult
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Renita Hall, conducted an unannounced visit to deliver findings regarding the above-mentioned allegations LPA was allowed entry by Art Vinarao, Caregiver. LPA identified herself and disclosed the purpose of the visit and elements of the findings with the Caregiver.

On December 02, 2020, the department received a complaint that an uncleared adult working at the facility. An investigation was initiated following an allegation that an uncleared adult was working within the facility, potentially violating safety and regulatory protocols. Interviews were conducted with facility staff and other relevant individuals. A review of employee records, and clearance documentation to determine the status of the individual in question.

Continued on 9099C-2
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Renita Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 08-AS-20201202155827
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: PARKWAY GARDENS RETIREMENT CARE HOME
FACILITY NUMBER: 374603513
VISIT DATE: 09/26/2024
NARRATIVE
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The investigation confirmed that the individual in question was not listed in the facility's clearance records. They did not possess the required background checks or clearance as an employee. The staff interviewed corroborated that the individual had been present in the facility without the proper clearance.

The allegation that an uncleared adult was an employee within the facility is substantiated as there is a preponderance of evidence to prove the alleged violation occurred. The individual was hired as a caregiver without the necessary background checks and approvals, which is a violation of Health and Safety Code section 1569.17 (e )(1).

An exit interview was conducted; a copy of this report along with Licensee Appeal Rights LIC 9058 (REV 3/22) were provided to Art Vinarao, Caregiver and his signature confirms receipt of these documents.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Renita Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 08-AS-20201202155827
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: PARKWAY GARDENS RETIREMENT CARE HOME
FACILITY NUMBER: 374603513
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/23/2024
Section Cited
HSC
1569.17(b)(1).
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(b)All individuals subject to a criminal record review pursuant ....... shall prior to working, residing or volunteering in a licensed facility:
(1) Obtain a California clearance or a criminal record exemption as required by the Department
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Immediate Action: Ensure that the uncleared individual do not have access to the facility until proper clearance is obtained. POC cleared on 12/14/2020
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This requirement was not met as evidenced by: Based on interview, records, and systems review, the licensee did not ensure Staff #1
had a CA criminal record clearance prior toworking or volunteering in the licensed facility which posed an immediate Health, Safety and Personal Rights Risk to person in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Renita Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 08-AS-20201202155827
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: PARKWAY GARDENS RETIREMENT CARE HOME
FACILITY NUMBER: 374603513
VISIT DATE: 09/26/2024
NARRATIVE
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On October 26, 2020, hospice staff documented wounds, of unknown staging, to R1’s forearm and coccyx. On November 25, 2020, hospice staff documented R1 was noted to have developed a stage 3 pressure injury. Interviews with outside medical professionals who visited the facility and observed R1 did not have concerns regarding neglect or unmet needs for R1. Additionally, there were no concerns regarding assistance with medication administration or mismanagement of R1’s medication. R1 passed away at the facility on November 26, 2020. According to the County of San Diego Certificate of Death, R1’s cause of death was listed as Cardiac Arrest and Respiratory Arrest with Hepatic failure, unspecified without coma, and Non-Alcoholic Cirrhosis of Liver noted as the underlying causes of death.

A review of records revealed R2 was non-ambulatory and required assistance with bathing, dressing, feeding, transferring, and incontinence care. R2 was able to communicate their needs. R2 began receiving hospice services from a hospice agency before their admission to the facility. Interviews with staff indicated staff checked on R2 approximately every two hours to assist with repositioning and assisted R2 with incontinence care. R2 was prescribed oxygen due to their medical condition. Interviews with medical professionals revealed R2 was oriented and able to operate their oxygen machine. Interviews with outside sources and outside medical professionals who visited the facility and observed R2 did not have concerns regarding neglect or unmet needs for R2. Additionally, there were no concerns regarding assistance with medication administration or mismanagement of R2’s medication. R2 passed away at the facility on October 3, 2020. R2’s cause of death was listed as Interstitial Lung Disease. Outside source and residents interviewed regarding the language barrier, there are no concerns, and staff could communicate with residents in their preferred language.


Based on the investigation findings, the allegations made against the staff regarding all allegations of Questionable Deaths, Staff Mismanagement of Residents' Medications, Staff Failure to Meet Residents' Needs, Untrained staff, and Staff Unable to Communicate with Residents Due to a Language Barrier—are unsubstantiated. A finding that is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

An exit interview was conducted with Art Vinarao, Caregiver. A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided to the Caregiver and his signature on this report confirms receipt of the Licensee Rights.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Renita Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5