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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603643
Report Date: 12/27/2021
Date Signed: 12/28/2021 08:11:08 AM

Substantiated


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
08/31/2021 and conducted by Evaluator Anna Kennedy
COMPLAINT CONTROL NUMBER: 08-AS-20210831142130
FACILITY NAME:ST. PAUL'S PLAZAFACILITY NUMBER:
374603643
ADMINISTRATOR:STRATMAN, KIMFACILITY TYPE:
740
ADDRESS:1420 E PALOMAR STREETTELEPHONE:
(619) 591-0600
CITY:CHULA VISTASTATE: CAZIP CODE:
91913
CAPACITY:300CENSUS: 138DATE:
12/27/2021
UNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Lindsay HahnTIME COMPLETED:
05:11 PM
ALLEGATION(S):
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Licensee failed to follow the admission agreement.
Facility staff mismanaged resident’s medication.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kennedy conducted an unannounced complaint visit to deliver investigative finding regarding the above allegations. LPA identified herself and was invited in to the facility.
LPA met with Lindsay Hahn, Resident Services Coordinator and discussed the purpose of today's visit.

During the course of the investigation, LPA collected records, conducted interviews with internal and external sources, and toured the facility.

The allegation that the licensee failed to follow the admission agreement is based on the increase in the care for Resident 1 (R1) (See LIC 811 for a list of confidential names).
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rebecca Hedgecock
LICENSING EVALUATOR NAME: Anna Kennedy
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2021
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 5
Control Number 08-AS-20210831142130
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: ST. PAUL'S PLAZA
FACILITY NUMBER: 374603643
VISIT DATE: 12/27/2021
NARRATIVE
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The admission agreement states that “If we determine that you need a different level of care than that which you are currently receiving , we will provide you and your responsible party, if applicable, with a written notice of the reasons for and the effective date, of the change." And “if you begin receiving a different level of care, the rate for the new level of care shall be charged immediately. We will give you written notice of a level of care rate increase within two (2) business days after providing services at the new level of care.” R1 was assessed by the facility to have needs beyond the care plan R1 was receiving. R1 was receiving enhanced care for two months prior to being charged for the additional care. When the facility determined that the rate would be changed to the higher level of care the facility did communicate with the responsible parties about the care provided and R1’s needs, however, they did not provide written notice to the responsible parties. This is in violation of the admission agreement and this allegation is Substantiated.

The allegation that the facility staff mismanaged resident’s medication was the result of an incident that resulted in R1 receiving a double dose of a supplement. The error occurred when R1 was admitted to a hospice agency for care. The facility had a supply of the supplement on hand for R1 and the hospice agency sent a supply of the supplement to the facility. Staff 1 (S1) gave doses of the supplement to R1 from both supplies resulting in R1 receiving a double dose of the supplement. S2 discovered the error and reported the error. The facility notified R1’s medial provider and R1’s responsible party. R1 was monitored closely and no ill effects were noted. Interviews revealed that the medication handling procedures broke down in two places contributing to the medication error. S3 accepted the medication and placed excess medication into the medication cart instead of the location for excess medication, and S1 did not check the Electronic Medication Administration Record when preparing to give R1 their medication. This allegation is Substantiated

A substantiated finding means the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited per Title 22, Division 6, Chapter 8 of the California Code of Regulations and is listed on LIC 9099-D.
This report was discussed with Lindsay Hahn, Resident Services Coordinator. A copy along with Licensee Rights (01/2016) was emailed to facility staff at the conclusion of the visit. An electronic response confirms the receipt of these documents.
SUPERVISORS NAME: Rebecca Hedgecock
LICENSING EVALUATOR NAME: Anna Kennedy
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2021
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
08/31/2021 and conducted by Evaluator Anna Kennedy
COMPLAINT CONTROL NUMBER: 08-AS-20210831142130

FACILITY NAME:ST. PAUL'S PLAZAFACILITY NUMBER:
374603643
ADMINISTRATOR:STRATMAN, KIMFACILITY TYPE:
740
ADDRESS:1420 E PALOMAR STREETTELEPHONE:
(619) 591-0600
CITY:CHULA VISTASTATE: CAZIP CODE:
91913
CAPACITY:300CENSUS: 138DATE:
12/27/2021
UNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Lindsay HahnTIME COMPLETED:
05:11 PM
ALLEGATION(S):
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9
Facility charged resident for services that were not agreed upon.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kennedy conducted an unannounced complaint visit to deliver investigative finding regarding the above allegation. LPA identified herself and was invited in to the facility.
LPA met with Lindsay Hahn, Resident Services Coordinator and discussed the purpose of today's visit.

During the course of the investigation, LPA collected records, conducted interviews with internal and external sources, and toured the facility.

Regarding the allegation is that the facility charged resident for services that were not agreed upon. Based on the documents and interviews with internal and external sources, it was determined that Resident 1 (R1) (See LIC 811 for a list of confidential names) had a significant medical event on 6/14/21 and was hospitalized for four days.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rebecca Hedgecock
LICENSING EVALUATOR NAME: Anna Kennedy
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2021
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-20210831142130
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: ST. PAUL'S PLAZA
FACILITY NUMBER: 374603643
VISIT DATE: 12/27/2021
NARRATIVE
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Prior to the medical event, R1 was independent in most areas receiving only assistance with medication management. Upon return to the facility R1 began receiving additional care including mobility assistance, assistance transferring, dressing and grooming and toileting. R1 was receiving therapy to increase the capacity to ambulate with modest results. R1 began having trouble swallowing and had a noted loss of appetite. R1 ate more when others visited with R1 and offered R1 encouragement. R1 was eventually placed on hospice. Although additional care was being provided to R1, the facility did not change for the higher care category for R1 initially. After two months and R1 being placed on hospice, the facility assigned R1 a higher category of care. R1’s responsible parties expressed disagreement with the change to the higher care category and stated so to facility management staff. Although R1’s responsible parties expressed that they were not in agreement with the increased rate, the facility began billing at the higher rate on 8-18-21.

The admission agreement states that “if you begin receiving a different level of care, the rate for the new level of care shall be charged immediately”. and “You agree to change to a level of care appropriate to your needs as required for continuing residency. The rate for the new level of care shall apply immediately”. Although the responsible parties may not have felt that the change in care level was warranted, they did agree to the charges for the additional care when the admission agreement was signed. Therefore, this allegation is Unsubstantiated.

A finding that the complaint is unsubstantiated means that there is not a preponderance of the evidence to prove that the alleged violation occurred.

This report was discussed with Lindsay Hahn, Resident Services Coordinator. A copy along with Licensee Rights (01/2016) was emailed to facility staff at the conclusion of the visit. An electronic response confirms the receipt of these documents.
SUPERVISORS NAME: Rebecca Hedgecock
LICENSING EVALUATOR NAME: Anna Kennedy
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 08-AS-20210831142130
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: ST. PAUL'S PLAZA
FACILITY NUMBER: 374603643
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/10/2022
Section Cited
CCR
87507(f)
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Admission Agreements The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. The facility failed to meet this requirement as evidenced by:
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Facility will develop a checklist to be used when a change of care level is considered, to include all items required in the admission agreement. The checklist will be submitted to CCL by the POC date.
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Documents and interviews revealed that the facility did not send a letter to the responsible parties with the reasons for and effective date of a change in care level posing a potential impact on the facility’s plan of operation.
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Type B
01/10/2022
Section Cited
CCR
87411(a)
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Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by:
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Facility will conduct an inservice training for medtechs to include checking medication in and checking the MAR prior to passing medications. Confirmation will be sent to CCL by POC date
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Documents and interviews revealed that medication handling procedures were not followed resulting in Resident 1 receiving a double dose of a prescribed medication posing a potential risk to one of 95 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.
SUPERVISORS NAME: Rebecca Hedgecock
LICENSING EVALUATOR NAME: Anna Kennedy
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5