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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603643
Report Date: 04/24/2025
Date Signed: 04/30/2025 08:23:41 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
03/24/2025 and conducted by Evaluator Ramon Serrano
COMPLAINT CONTROL NUMBER: 08-AS-20250324154907
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: 126DATE:
04/24/2025
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Maria SanoTIME COMPLETED:
04:13 PM
ALLEGATION(S):
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Staff did not prevent a resident from eloping out of a window while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced complaint visit to deliver findings on the above allegation. LPA met with Executive Director Maria Sano and we discussed the purpose of the visit and elements of the complaint.

Community Care Licensing (CCL) has investigated the above allegation. The investigation consisted of LPA observation, records review, interviews with staff, outside sources and outside agency.

It was alleged that facility staff did not prevent a resident from eloping out of a window. It was reported that Resident 1 (R1) fell from a bedroom window in the memory care unit. It was further reported that the fall was approximately eight feet and R1 sustained minor injuries.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
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-20250324154907
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: ST. PAUL'S PLAZA
FACILITY NUMBER: 374603643
VISIT DATE: 04/24/2025
NARRATIVE
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LPA reviewed R1's physician's report dated September 9, 2024. Physician's report revealed the following; R1 had a primary diagnosis of severe vascular dementia with other behavioral disturbance. R1 was confused, disoriented and had wandering behavior. R1 was not able to leave the facility unassisted. R1's care plan dated March 16, 2022 indicated that elopement was one of R1's "problems." The care plan stated that R1 would be monitored by care staff and personally checked on at least every two hours. LPA searched the CCL incident report database and found three reports were submitted to CCL regarding R1 eloping. The incident reports were dated February 13, 2023, April 13, 2024 and March 22, 2025.

LPA interviewed Staff 1 (S1) who stated that on March 22, 2025 at approximately 4:45PM they were alerted by a resident that their was "somebody in the bushes." S1 stated that they immediately ran towards the front of the facility and found R1 seated in the car of a "good samaritan." S1 stated that they then asked another staff member to assist them in escorting R1 back to the facility. S1 stated that R1 had no visible injuries at the time but was extremely agitated. S1 then asked the front desk to call emergency services as a precaution. S1 stated that R1 had a history of exit seeking and eloped from the facility approximately two to three times. S1 confirmed that in each occasion R1 "completely left the facility" without staff knowledge. S1 stated that the memory care unit was "short staffed" on the day of the incident which resulted in the closure of one of the housing units. S1 stated when one of the housing units is "closed" staff is required to monitor and care for more residents. S1 stated that several of these residents were "total assist" or bedridden which means that they required more time and assistance from the care givers.

LPA interviewed Staff 2 (S2) who stated that their was a lot of "chaos" on the day of the incident. S2 explained that one of the housing units was closed in memory care which resulted in 17 residents being placed in the day room for supervision. S2 stated that throughout most of the morning and afternoon the residents were crying and in need of care. S2 stated that at some point in the afternoon R1 got up from the dayroom area and walked towards their room, which was located in the housing unit that was closed for the day. S2 stated that R1 walked past their housing unit, into the subsequent housing unit, entered room #138, opened the window and escaped. S2 stated that they were not aware that R1 got up and left the television area. S2 stated that R1 had "escaped" the facility four times. S2 stated that on a separate occasion, R1 left the facility and walked into a 7-eleven at the corner. S2 stated that R1 was escorted back to the facility by a passerby who assumed they lived at the facility. S2 stated that they are aware R1's care plan indicated that R1 was to be checked on every two hours but due to the staff shortage it was not realistic.
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 08-AS-20250324154907
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: ST. PAUL'S PLAZA
FACILITY NUMBER: 374603643
VISIT DATE: 04/24/2025
NARRATIVE
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LPA interviewed Outside Source 1(OS1) who stated that R1 was found in the bushes by a resident that resides in assisted living. OS1 stated that they were upset with the incident after they personally stood outside of the window, on the sidewalk and determined the fall was over six feet. OS1 stated that in the past R1 had followed behind staff and visitors who were exiting the memory care unit and had successfully eloped. OS1 stated that these incidents usually occur on the weekends which led them to believe that they were short staffed on weekends. OS1 stated that on most eloping incidents it is not the staff who located R1 but rather other residents or law enforcement.

LPA interviewed Executive Director (ED) who stated that she was at the facility on the morning of March 22, 2025, but left prior to the incident. ED stated that staff called her to advise of the incident and she returned to the facility. ED stated that staff advised her that they were focused on two residents that were crying and combative during the time that R1 eloped. ED stated that a staff member received a call that a resident fell from a bedroom window. ED stated that staff immediately went outside, located R1 and brought R1 back to the facility. ED stated that staff then made calls to emergency services, responsible party and an outside agency. ED further stated that after the incident she asked maintenance to fix the broken plastic window stoppers and the screen in room #138.

On April 21, 2025 LPA conducted a re-enactment of R1's actions on the day of the incident. LPA walked from the dayroom area towards room#138. LPA entered the room and attempted to open the bedroom windows. LPA observed two plastic "stoppers" which prevented the windows to be completely opened. LPA determined that it would have taken considerable force and time to break the plastic "stoppers" and open the window completely. LPA then walked outside of the facility, in front of room #138. LPA determined that the drop from the bedroom windows to the ground level below was approximately eight feet, as was reported.

The Department has investigated the complaint alleging staff did not prevent a resident from eloping out of a window while in care. Based on evidence obtained, facility staff were not aware of R1’s whereabouts for some time despite R1’s documented exit seeking behavior and need for safety checks. Accordingly, the above allegation is substantiated. This finding means that the preponderance of the evidence standard has been met and the allegation is valid. The deficiency is cited in accordance with California Code of Regulations, Title 22, Division 6, Chapter 8 and noted on the attached LIC 9099-D.
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 08-AS-20250324154907
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ST. PAUL'S PLAZA
FACILITY NUMBER: 374603643
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/29/2025
Section Cited
CCR
87464(f)(1)
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87464 Basic Services (f)(1).... “Care and Supervision” means the facility assumes responsibility for…on going assistance with activities of daily living and the assumption of varying degrees of responsibility for the safety and well-being of residents.
This requirement was not met as evidenced by:
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Licensee agreed to conduct training by an outside source on elopements/absent without leave (AWOL), supervision for residents in care. This training will be scheduled by 4/25/25 and trainings will be completed by POC date of 4/29/25.
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Based on LPA observation, interviews and record review the licensee did not provide R1 supervision which affected R1's safety and well being. 1 in 1 of 127 persons in care [R1] which posed an immediate Health and safety risk to persons 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: Robyn Clark
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 08-AS-20250324154907
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: ST. PAUL'S PLAZA
FACILITY NUMBER: 374603643
VISIT DATE: 04/24/2025
NARRATIVE
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An exit interview was conducted, a plan of correction was jointly developed, and a copy of this report and Licensee/Appeal Rights (LIC 9058) were provided to Maria Sano, Executive Director. Signature on this form confirms receipt of the documents.
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5