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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603643
Report Date: 07/19/2022
Date Signed: 07/19/2022 11:09:41 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
02/11/2020 and conducted by Evaluator Sabel Martinez
COMPLAINT CONTROL NUMBER: 08-AS-20200211084533
FACILITY NAME:ST. PAUL'S PLAZAFACILITY NUMBER:
374603643
ADMINISTRATOR:CAMPBELL, RHONDAFACILITY TYPE:
740
ADDRESS:1420 E PALOMAR STREETTELEPHONE:
(619) 239-6900
CITY:CHULA VISTASTATE: CAZIP CODE:
91913
CAPACITY:300CENSUS: 154DATE:
07/19/2022
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Executive Director, Kim StratmanTIME COMPLETED:
11:20 AM
ALLEGATION(S):
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Staff did not conduct welfare check resulting in delayed medical care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegation. The LPA was greeted by Executive Director, Kim Stratman, identified himself, and disclosed the purpose of the visit.

The Department’s investigation consisted of review of records, and interviews with internal and external sources.

It was alleged staff did not conduct a welfare check resulting in delayed medical care. Resident records and interviews revealed resident 1 (R1) was independent of care and supervision and resided in the independent section of the facility. The facility has a policy in place to determine when it is necessary to conduct a welfare check of residents residing in that section. Interviews with multiple staff confirmed the facility has a door hanger/placard policy to ensure wellfare checks. The placard must be placed outside the door every night by 10pm, indicating the resident is retiring for the night.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022
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-20200211084533
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: 07/19/2022
NARRATIVE
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If a door does not have a placard by 10pm, staff will review the Out on Leave list indicating the possible reasons why the resident may not be in the room. If the room in question is not on the list, staff will then conduct a wellfare check. Additionally, the residents must remove the placards in the morning to indicate they are up and safe. If the placard is not removed by 10am, staff will then conduct a wellfare check. Resident 1’s (R1) placard was last seen on the night of 2/2/2020 and was removed on the morning of 2/3/2020. The night of 2/3/2020, R1’s placard was not placed on the door, staff mistakenly believed R1 was out of the facility at the hospital and no wellfare check was conducted. Interview with management confirmed R1 was not on the Out on Leave list as believed and a wellfare check should have been conducted. Interviews and an Unusual Incident/Injury Report submitted to the Department indicated R1 was found lying on the floor by a family member, on 2/4/2020, at approximately 10am. The family member summoned staff and 9-1-1 was activated. Interview with an outside source revealed R1 fell the evening of 2/3/2020; thus, was on the floor for approximately 15 hours.

Obtained medical records for R1’s hospitalization on 2/4/2020 revealed the following diagnoses upon admission: severe dehydration, weakness, Atrial fibrillation, urinary tract infection, and elevated Creatine Kinase. R1 was hospitalized and discharged on 2/8/2020 to a skilled nursing facility for rehabilitation. Based on the evidence gathered from records, and interviews with internal and external sources, the preponderance of evidence standard was met to Substantiate the above allegation. Per California Code of Regulations, Title 22, this deficiency was cited in an LIC 809D. A Plan of Correction was jointly developed with the licensee.

An exit interview was conducted with Executive Director, Kim Stratman, to whom a copy of this report, LIC 809D and Licensee's Rights (LIC 9058 01/16) were provided to.

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20200211084533
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: 07/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/19/2022
Section Cited
CCR
87468.2(a)(8)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement is not met as evidenced by:
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Facility has implented a wellfare check policy. When a placard is not placed on the resident's door, staff must conduct a visual wellnfare check, regardless of the room/resident being on the out on leave, or out at the hospital list.
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Based on interviews and records reviewed, the licensee did not ensure resident (R1) was free of neglect,which posed an immediate Health, Safety, and Personal Rights risk to 1 of 154 persons in care.
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ED will conduct in service training of all staff regarding the new policy and procedures. ED will submit proof of trained staff and futire scheduled training sessions, by 7/20/2022.
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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: Denise Powell
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022
LIC9099 (FAS) - (06/04)
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