374603584-12-14-2022-08-AS-SJAB-CMHTUG-20221227140220

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603584
Report Date: 12/14/2022
Date Signed: 12/14/2022 10:58:23 AM

Unsubstantiated

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
10/16/2020 and conducted by Evaluator Elizabeth Hamilton

COMPLAINT CONTROL NUMBER: 08-AS-20201016110128

FACILITY NAME:	ACTIVCARE AT MISSION BAY		FACILITY NUMBER:	374603584
ADMINISTRATOR:	DESTEFANI, DAWN		FACILITY TYPE:	740
ADDRESS:	2440 GRAND AVENUE		TELEPHONE:	(858) 270-8000
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92109
CAPACITY:	60	CENSUS: 50	DATE:	12/14/2022
		UNANNOUNCED	TIME BEGAN:	10:05 AM
MET WITH:	Executive Director, Dawn Destefani		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Staff did not keep resident's room free from odor.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Elizabeth Hamilton conducted an unannounced complaint investigation visit at the facility. LPA gained access to the facility, met with Executive Director, Dawn Destefani, identified herself and explained the purpose of the visit which was to deliver findings for the above allegation.

The Department’s investigation consisted of records review, observations, interviews with staff and outside sources.

On October 16, 2020, it was alleged that sometime between August 2020 and October 2020, staff did not keep resident’s room free from odor. It was specifically alleged that resident 1 (R1) would urinate off the side of their bed onto carpet and staff would not clean it. LPA toured the facility and did not identify any foul odors in the facility. Interviews with outside sources revealed that there were no concerns with any odors in the facility. LPA Interviews with staff confirmed all resident rooms with carpets were cleaned weekly with a sprayed deodorizer and disinfectant.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Elizabeth Hamilton	TELEPHONE: (619) 929-7590
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022

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-20201016110128

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: ACTIVCARE AT MISSION BAY	FACILITY NUMBER: 374603584
	VISIT DATE: 12/14/2022

NARRATIVE

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Interviews with staff further revealed, if there was an accident or a spill, then the rooms were cleaned as often as needed. There was not enough evidence to support this allegation.

The Department has investigated the allegation listed above. Based on evidence obtained, including observations, interviews and records reviewed, the above allegation is determined to be unsubstantiated as the Department could not meet the preponderance of the evidence standard. An exit interview was conducted with Executive Director, Dawn Desefani and a copy of this report and Licensee/Appeals Rights (LIC 9058 01/16) was provided.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Elizabeth Hamilton	TELEPHONE: (619) 929-7590
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022

LIC9099 (FAS) - (06/04)

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