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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603565
Report Date: 11/02/2020
Date Signed: 11/02/2020 12:06:55 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
02/13/2020 and conducted by Evaluator Natasha Persaud
COMPLAINT CONTROL NUMBER: 08-AS-20200213160446
FACILITY NAME:LA VIDA REALFACILITY NUMBER:
374603565
ADMINISTRATOR:LITTLEFIELD, RUELFACILITY TYPE:
740
ADDRESS:11588 VIA RANCHO SAN DIEGOTELEPHONE:
(619) 660-5778
CITY:EL CAJONSTATE: CAZIP CODE:
92019
CAPACITY:177CENSUS: 100DATE:
11/02/2020
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Assistant Executive Director, Kimberly GarciaTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Staff inappropriately grabbed resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Natasha Persaud contacted the facility via video conference, due to COVID-19, to conclude a complaint investigation. LPA identified herself and discussed the purpose of the call with Assistant Executive Director, Kimberly Garcia.

During the investigation, LPA conducted a tour of the facility, obtained facility records, and conducted interviews with staff, residents, and outside sources. It was alleged Staff #1 (S1) inappropriately grabbed Resident #1 (R1). Investigation revealed S1 grabbed R1 in the private area through their clothing to check if R1’s adult briefs were soiled. Investigation revealed S1 admitted to placing their hand in R1’s private area over R1’s clothing to check if R1’s adult briefs were soiled. S1’s interview revealed due to R1 refusing care it was easier to conduct a quick hand check through their clothing. Staff interviews revealed R1 refuses care, removes their own adult briefs and throws them on the floor daily. Additional staff interviews revealed R1 can toilet independently but receives staff assistance to ensure proper hygiene. R1’s Service Plan indicated R1 requires physical assistance with parts of toileting tasks to include adult briefs, and urinary pads. Continued on an LIC 9099C.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2020
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 5
Control Number 08-AS-20200213160446
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: LA VIDA REAL
FACILITY NUMBER: 374603565
VISIT DATE: 11/02/2020
NARRATIVE
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Based on interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 8 is being cited on the attached LIC 9099D. [See LIC 811 Confidential Names List to identify Resident #1 and Staff #1]. An exit interview was conducted with Assistant Executive Director, Kimberly Garcia, via virtual visit, and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided to the Assistant Executive Director via electronic mail. An electronic read receipt confirmation was requested to be sent by the Assistant Executive Director upon receipt of the documents.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
02/13/2020 and conducted by Evaluator Natasha Persaud
COMPLAINT CONTROL NUMBER: 08-AS-20200213160446

FACILITY NAME:LA VIDA REALFACILITY NUMBER:
374603565
ADMINISTRATOR:LITTLEFIELD, RUELFACILITY TYPE:
740
ADDRESS:11588 VIA RANCHO SAN DIEGOTELEPHONE:
(619) 660-5778
CITY:EL CAJONSTATE: CAZIP CODE:
92019
CAPACITY:177CENSUS: 100DATE:
11/02/2020
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Assistant Executive Director, Kimberly Garcia.TIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Licensee did not meet the needs of resident #1
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Natasha Persaud contacted the facility via video conference, due to COVID-19, to conclude a complaint investigation. LPA identified herself and discussed the purpose of the call with Assistant Executive Director, Kimberly Garcia.

During the investigation, LPA conducted a tour of the facility, obtained facility records, and conducted interviews with staff, residents, and outside sources. It was alleged Licensee did not meet the needs of Resident #1 (R1) by R1 being left in soiled clothing and soiled adult briefs. R1’s Physician Report indicated R1 has a Major Neurocognitive Disorder, bladder impairment, and is unable to care for own toileting needs. Staff interviews revealed R1 removes their adult briefs independently and throws them on the floor. In addition, R1 refuses assistance from caregivers. Additional staff interviews revealed R1 is not left in soiled clothing or adult briefs, as R1 independently removes them. Facility’s End of Shift Reports dated 02/13/20, 02/18/20, and 02/19/20 reflect R1 found without no depends, an resident continued to remove depends. Staff interviews revealed R1 is checked on at least every two hours or more if needed. Continued on an LIC 9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 08-AS-20200213160446
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: LA VIDA REAL
FACILITY NUMBER: 374603565
VISIT DATE: 11/02/2020
NARRATIVE
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Additional interviews revealed R1 will be found by staff sitting in their chair without any adult briefs and sometimes no underwear. Therefore, due to R1 being able to remove their own items, R1 is not observed in soiled clothing or soiled adult briefs. Staff interviews also revealed R1 is observed dry during staff rounds/checks.

Based on interviews conducted, investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegation. The allegation is found Unsubstantiated. An exit interview was conducted with Assistant Executive Director, Kimberly Garcia, via virtual visit, and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided to the Assistant Executive Director via electronic mail. An electronic read receipt confirmation was requested to be sent by the Assistant Executive Director upon receipt of the documents. [See LIC 811 Confidential Names List to identify Resident #1].
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2020
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 08-AS-20200213160446
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: LA VIDA REAL
FACILITY NUMBER: 374603565
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/09/2020
Section Cited
CCR
87468.1(a)(1)
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Personal Rights of Residents in All Facilities. To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by:
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Assistant Executive Director, Kimberly Garcia stated Staff #1 is no longer employed at the facility. Assistant Executive Director stated they will conduct In-Service Training on Personal Rights and Incontinent Care, and submit proof of documentation.
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Licensee did not ensure R1 was accorded dignity with S1. This poses a potential personal rights rick to residents 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.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2020
LIC9099 (FAS) - (06/04)
Page: 5 of 5