<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603617
Report Date: 06/18/2021
Date Signed: 06/18/2021 01:48:36 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
05/21/2021 and conducted by Evaluator Laarni Santiago
COMPLAINT CONTROL NUMBER: 08-AS-20210521161926
FACILITY NAME:TORREY PINES SENIOR LIVINGFACILITY NUMBER:
374603617
ADMINISTRATOR:MCDONALD, JASONFACILITY TYPE:
741
ADDRESS:13101 HARTFIELD AVETELEPHONE:
(858) 259-2222
CITY:SAN DIEGOSTATE: CAZIP CODE:
92130
CAPACITY:125CENSUS: 69DATE:
06/18/2021
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Jacqueline Wehner, Human Resources DirectorTIME COMPLETED:
01:55 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained minor injury while in care due to neglect
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Laarni Santiago conducted an unannounced complaint visit to deliver findings on the above-mentioned allegation. LPA was granted entry, identified herself and met with Human Resource Director, Jacqueline Wehner to discuss the purpose of the visit.

The Department's investigation consisted of interviews with staff, residents, review of records, and a brief review of the facility's transport vehicle. It was alleged that facility staff failed to secure the vehicle wheelchair lift for Resident 1 (R1) which resulted in their fall and sustained a minor injury. Administrator was provided an LIC 811 to identify R1. Evidence obtained from staff and resident interviews confirmed that while unloading R1 from the vehicle, staff forgot to hit the lift button to secure the platform so that R1 could safely lower to the ground. Interviews revealed that staff rolled R1 backwards and did not realize that the lift wasn't elevated and secured until R1 was already at the edge. Staff attempted to retract R1's wheelchair but due to the weight, R1 fell backwards and sustained a laceration to the head.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 318-5974
LICENSING EVALUATOR NAME: Laarni SantiagoTELEPHONE: (619) 318-5974
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021
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-20210521161926
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: TORREY PINES SENIOR LIVING
FACILITY NUMBER: 374603617
VISIT DATE: 06/18/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The Department has investigated the allegation that the resident sustained a minor injury while in care due to neglect and has found that, based upon interviews and record review, the preponderance of the evidence standard has been met. Therefore, this allegation is deemed substantiated.

This deficiency is noted on the attached 9099-D, and is cited in accordance with the California Code of Regulations, Title 22. An exit interview was conducted with Human Resource Director, Jacqueline Wehner, and a copy of this report, along with Licensee Rights (LIC 9058 01/16), were provided to the Administrator via electronic mail. An electronic read receipt confirms document was received.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 318-5974
LICENSING EVALUATOR NAME: Laarni SantiagoTELEPHONE: (619) 318-5974
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20210521161926
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: TORREY PINES SENIOR LIVING
FACILITY NUMBER: 374603617
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/18/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/25/2021
Section Cited
CCR
87411(a)
1
2
3
4
5
6
7
Personnel Requirements - General:
Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
1
2
3
4
5
6
7
Licensee conducted an in-service refresher training course with staff responsible for the incident soon after the incident. Proof of training has been provided to LPA during the subsequent visit.

Deficiency has been cleared. No further corrections needed.
8
9
10
11
12
13
14
This regulation was not met based on evidence by: Based on interviews and review of records, facility staff failed to elevate and secure R1's lift to ensure safety which resulted in a fall. This poses a potential safety risk to the 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 JacobTELEPHONE: (619) 318-5974
LICENSING EVALUATOR NAME: Laarni SantiagoTELEPHONE: (619) 318-5974
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3