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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603643
Report Date: 05/12/2025
Date Signed: 05/13/2025 02:34:14 PM

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
04/04/2025 and conducted by Evaluator Ramon Serrano
COMPLAINT CONTROL NUMBER: 08-AS-20250404172519
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:
05/12/2025
UNANNOUNCEDTIME BEGAN:
08:49 AM
MET WITH:Maria SanoTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Lack of supervision resulted in resident sustaining injury
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, residents and outside sources.

It was alleged that lack of supervision resulted in Resident 1 (R1) sustaining an injury. It was reported that R1 was pushed to the ground by Resident 2 (R2) resulting in a hematoma on their head. LPA conducted a records review on April 11, 2025. Review of R1's physician's report revealed that R1 had a primary diagnosis of severe dementia with agitation, R1 was not able to leave the facility unassisted and R1 was both confused and disoriented at times. Review of R1's care plan revealed that R1 had a history of falls and as a result, facility interventions were put into place.


Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2025
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 4
Control Number 08-AS-20250404172519
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: 05/12/2025
NARRATIVE
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Records review further revealed an incident report was submitted to CCL on April 4, 2025. Incident report stated that on April 3, 2025 at 435pm facility staff found R1 lying supine in front of room #144. R1 was assisted to their feet and advised staff that they did not know what happened but R2 was seen walking away from the area. Resident 3 (R3) then asked R2: "why did you do that to my friend?" R1 sustained a hematoma to their head as a result of the fall. Review of R2's care plan revealed R2 had a history of agitation evidenced by: swinging, hitting, yelling and cursing at staff.

LPA attempted to interview R1 on April 11, 2025. R1 was unable to answer qualifying questions. R1 was unable to state the date or time. LPA then asked R1 basic questions regarding their recent fall. R1 questioned "who fell?" LPA asked R1 if they had fallen recently and hit their head. R1 stated that they did not think that they had fallen recently and that they were fine.

LPA attempted to interview R2 on April 11, 2025. LPA asked R2 several qualifying questions. R2 began to speak unintelligibly while simultaneously pointing to different areas of their room. LPA asked R2 if they recalled pushing R1 to the ground. R2 again speaking unintelligibly and then closed their bathroom door and exited their bedroom. R2 then proceeded to continue to walk throughout the memory care unit.

LPA attempted to interview R3. R3 was unable to answer qualifying questions. R3 stated "a lot was going on that night." LPA asked R3 if they recalled R2 pushing R1. R3 stated that they could not remember what happened.

LPA interviewed Outside Source (OS) who stated that they were out of town when the incident occurred and they were advised by the facility that R1 was pushed by R2 causing R1 to fall on the ground. OS stated that the facility informed them that they were keeping R2 away from R1. OS stated that they believed this was an isolated incident and that R1 should remain at the facility.

LPA Interviewed Staff 1 (S1) who stated that they did not work on the date of the incident but they did work the following day. S1 stated that they read in the internal facility report that R1 was pushed to the ground by R2 and was sent to the hospital. S1 stated that R2 had a history of both verbal and physical aggression. S1 stated that R2 was physically aggressive with another resident but could not remember who or when exactly it occurred.


SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 08-AS-20250404172519
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: 05/12/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/02/2025
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.
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Licensee agreed to conduct a staff training focusing on Dementia and supervision of residents in care. This training will be completed by POC date of 6/2/25. Licensee will provide LPA with a signed training roster and traning agenda.
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Based on LPA interviews and records review the licensee did not provide R1 supervision which affected R1's safety and well being. 1 in 1 of 130 persons in care [R1] which posed a potential 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: 05/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 08-AS-20250404172519
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: 05/12/2025
NARRATIVE
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LPA interviewed Staff 2 (S2) on April 28, 2025. S2 stated that they did not work on the date of the incident but they were informed the following day of what occurred. S2 stated that R1 was pushed to the ground by R2. S2 was advised that R2 was being very aggressive on the day of the incident and they pushed R1. S2 stated that in the past R2 has been aggressive with both residents and staff including S2. S2 stated that R2's responsible party was advised of their aggressive behaviors and their medications were adjusted as a result.

LPA interviewed Executive Director (ED) who stated that R1, R2 and R3 walk around the memory care unit on a daily basis, not necessarily together. On the date of the incident R1 was seen approaching R2 in a corner of the unit. R1 was seen facing and talking to R2 when R2 suddenly pushed R1 causing R1 to fall back and hit their head. ED stated that a CNA was nearby serving food but could not stop or prevent the incident. ED stated that the incident was then reported to CCL.

The Department has investigated the complaint alleging lack of supervision resulted in R1 sustaining an injury. Based on evidence obtained R1 was injured after being pushed by R2. 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.

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: 05/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4