374603625-12-17-2021-08-AS-IESA-CB7UTR-20220131145221

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603625
Report Date: 12/16/2021
Date Signed: 12/17/2021 09:36:56 AM

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
11/03/2020 and conducted by Evaluator Debbie Correia

COMPLAINT CONTROL NUMBER: 08-AS-20201103161000

FACILITY NAME:	STELLAR CARE		FACILITY NUMBER:	374603625
ADMINISTRATOR:	LINDA CHO		FACILITY TYPE:	740
ADDRESS:	4518 54TH STREET		TELEPHONE:	(619) 287-2920
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92115
CAPACITY:	120	CENSUS: 82	DATE:	12/16/2021
		UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Activities Director Rachel Robinson		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Resident sustained a fracture while in care due to lack of supervision.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Correia conducted an unannounced visit to deliver investigative findings on the above listed complaint allegation. LPA Correia met with Licensee Activities Director (AD) Rachel Robinson to whom was explained the purpose for the visit.

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

It was alleged Resident1 (R1) (See Confidential Names List LIC 811) sustained a hip fracture from an unwitnessed fall due to lack of supervision. On October 31, 2020 at approximately 6:00 AM, Caregiver1 (C1) heard R1 shouting and went to check on R1. Upon arrival, C1 found R1 on the floor and discovered that another Resident2 (R2) had wandered into R1’s bedroom. R2 was insisting to C1 that R1’s bedroom was theirs. Interviews and records review revealed R2 had two recent changes in bedrooms due to changes in condition, due to falls and increased agitation and aggression.

Unsubstantiated

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: 12/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2021

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-20201103161000

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: STELLAR CARE	FACILITY NUMBER: 374603625
	VISIT DATE: 12/16/2021

NARRATIVE

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During interviews, it was established that C1 had checked on R1 10 to 15 minutes prior to the shouting. Interviews with staff revealed R1 reported being pushed down by R2, but R2 denied it. R1’s statements to medical professionals corroborated being pushed down but at that time R1 was unable to identify the person.
Interviews with facility staff revealed no one saw R2 wander into R1’s bedroom, or R1’s fall. Staff interviews revealed R1 often left their bedroom door open and R2 is known to roam the halls. The facility camera was not checked, and the video only lasts 48 hours. A Med-tech came to assist and R1 was transferred to the hospital. R1 was diagnosed with a hip fracture requiring surgery. Subsequently R1 was discharged with new care orders and returned to the facility. A review of R2’s records revealed that the Licensee was working with R2’s doctor on their rapid decline and need of higher level of care. The doctor could not explain the significant decline in cognitive level in such a short period of time and was considering Hospice Care. R2 had no injuries but was transferred to UCSD for a psychiatric evaluation and did not return to the facility.

Due to lack of corroborating evidence, the finding regarding the above allegation was established to be unsubstantiated. This finding means although the allegation may have happened, or could be valid, there is not a preponderance of evidence to prove that the alleged violation occurred.

An exit interview was conducted with AD Robinson and a copy of this report along with Licensee Rights (LIC 9058 01/16) was provided to AD Robinson via email. An electronic email read receipt confirms the documents were received.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie Correia	TELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2021

LIC9099 (FAS) - (06/04)

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