374603643-7-17-2025-08-AS-APAO-DKB5DE-20250806195148

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603643
Report Date: 07/17/2025
Date Signed: 07/17/2025 03:32:57 PM

Unsubstantiated

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
05/22/2025 and conducted by Evaluator Ramon Serrano

COMPLAINT CONTROL NUMBER: 08-AS-20250522163321

FACILITY NAME:	ST. PAUL'S PLAZA		FACILITY NUMBER:	374603643
ADMINISTRATOR:	STRATMAN, KIM		FACILITY TYPE:	740
ADDRESS:	1420 E PALOMAR STREET		TELEPHONE:	(619) 591-0600
CITY:	CHULA VISTA	STATE: CA	ZIP CODE:	91913
CAPACITY:	300	CENSUS: 120	DATE:	07/17/2025
		UNANNOUNCED	TIME BEGAN:	08:57 AM
MET WITH:	Chardonnay Blue		TIME COMPLETED:	03:40 PM

ALLEGATION(S):

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Staff did not follow infection control protocols.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced complaint visit to investigate and deliver findings on the above allegation. LPA met with Resident Clinical Specialist Chardonnay Blue and we discussed the purpose of the visit and elements of the complaint.

Community Care Licensing (CCL) has investigated the above allegations. The investigation consisted of records review, interviews with facility staff, resident and outside sources.

It was alleged that facility staff did not follow infection control protocols. It was reported that Resident 1 (R1) had an infectious skin condition (scabies) and was not isolated in their room in the memory care unit. It was also reported that facility staff were not following infection control protocols including the use of personal protective equipment (PPE). LPA reviewed R1's physician's report dated March 5, 2025. R1 has a diagnosis of vascular dementia with behavior disturbance and R1 is confused and disoriented at times. R1's careplan indicated that R1 has episodes of agitation evidenced by yelling, swinging, hitting and cursing at staff.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025

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-20250522163321

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: 07/17/2025

NARRATIVE

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LPA interviewed R1 at the facility. R1 stated that they have lived at the facility seven years and they like the facility a lot. R1 had no recollection of having scabies or any type of skin condition. R1 had no recollection of being isolated in their room for an extended period of time. R1 had no recollection of staff redirecting R1 back to their room during R1's period of quarantine.

LPA interviewed Staff 1 (S1) who stated that he has worked in the memory care unit for over two years. S1 stated that a facility Nurse informs the staff of the "contact precaution" for a resident with scabies. S1 stated that the staff are then provided with PPE including gloves and gowns. S1 stated that the resident is quarantined in their room until their treatment has ended. S1 stated that R1 in general is aggressive and tends to wander around the unit. S1 stated that when they would see R1 attempt to leave their room the staff would redirect R1 back to their room. S1 stated that R1 would remain in their room for a couple of hours and would try to exit again. S1 stated that again staff would redirect R1 back inside of their room. S1 stated that after PPE was used on R1 staff would remove the PPE and place it in the trash can outside of R1's room. S1 stated that the trash can was placed outside of the room due to R1's tendency to empty out any trash can that is left in their room. S1 stated that they are familiar with infection control procedures due to their work experience.

LPA interviewed Staff 2 (S2) who stated that they work directly with the memory care residents. S2 stated that whenever a resident is diagnosed with scabies the staff follow the "standard isolation precaution." S2 stated that they isolate the resident from other residents. S2 stated that this can be difficult to achieve with residents in the memory care unit. S2 stated that staff put on PPE every time they enter the isolated resident's room and also practice hand hygiene. S2 stated that when R1 was first placed on isolation for scabies their were no issues, but after several days in isolation R1 became more irritable. S2 explained that R1 normally has "behaviors" regardless if R1 is in isolation or not. S2 stated that these behaviors just increased due to R1 not understanding why they had to remain in their room. S2 stated that to help R1 facility staff would talk and comfort R1 and if possible the med tech would give R1 their "PRN."

LPA interviewed Staff 3 (S3) who stated that they work directly with the residents in the memory care unit. S3 stated that when a resident has scabies PPE is placed outside of their room. S3 stated that the staff are aware that the resident is on isolation, if the resident attempts to leave their room the staff redirect the resident. S3 stated that if the resident touches something outside of their room the staff clean and disinfect the area. S3 stated that staff are required to put on PPE before entering the resident's room and then dispose of the PPE in the bio hazard trash can outside of the room.

SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 08-AS-20250522163321

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: 07/17/2025

NARRATIVE

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S3 stated that they worked with R1 towards the end of R1's isolation period. S3 stated that R1 was mostly compliant in regards to isolating in their room.

LPA interviewed Staff 4 (S4) who stated that they have worked at the facility over 5 years. S4 stated that their is a facility protocol for scabies or any infectious disease. S4 stated that residents are placed on quarantine and a "box" is place in front of the resident's room. S4 stated that a sign is also placed on the door so that housekeeping does not enter the resident's room. S4 stated that the memory care staff enter the room in "twos" so that they prevent cross contamination. S4 stated that staff report rashes or scabies to the LVN who then contact's the Doctor and they are given medicine, such as a cream. S4 stated that PPE is always used when in contact with an infected resident. S4 stated that for the first 2-3 days on isolation R1 was "okay" S4 stated that R1 would yell and cry due to their diagnosis and behaviors. S4 stated that staff would reassure R1 and advise R1 that they were ill and it was best for R1 to remain in quarantine. S4 stated that as soon as R1 tried to leave their room the staff would immediately redirect R1 back to their room. S4 stated that after awhile R1 became accustomed to the routine of staying in their room. S4 stated that a bio hazard trash bin was located outside of R1's room where the PPE was discarded. S4 stated that PPE trash is kept separate from regular trash items. S4 stated that they have never witnessed staff keep on PPE or walk around with PPE after leaving an infected resident's room.

LPA interviewed Outside Source (OS) who stated that facility staff were not initially following proper infection control protocol with R1. OS stated that after several days, facility management addressed the issue with staff. OS stated that facility staff began to follow proper infection control protocol including PPE usage after management intervened.

At the time this report was written both the Executive Director and the Director of Nursing were no longer employed at the facility. LPA was unable to document a statement from either of them regarding the allegation.

LPA reviewed facility charting notes dated May 14, 2025 through May 28, 2025. Charting notes indicated that on May 21, 2025 new doctor's orders were received for R1. R1 was placed on contact isolation and was given a medication to treat scabies. Instructions stated that R1's clothes and bedding were to be washed in hot water. It should be noted that the facility conducted a staff training titled; scabies policy and procedure dated May 21, 2025, June 2, 2025 and June 3, 2025. 28 staff members attended and signed the training log.

SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 08-AS-20250522163321

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: 07/17/2025

NARRATIVE

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Based upon the foregoing, the above listed allegation is unsubstantiated. This finding means that the preponderance of the evidence standard has not been met and the allegation is unsubstantiated.

An exit interview was conducted with Chardonnay Blue. A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to Chardonnay Blue whose signature below verifies receipt of these rights.

SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025

LIC9099 (FAS) - (06/04)

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