374603643-10-29-2025-08-AS-SMAZ-DMX7BC-20251029213051

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603643
Report Date: 10/29/2025
Date Signed: 10/29/2025 03:00:20 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
12/06/2023 and conducted by Evaluator Marisela Garcia-Centeno

COMPLAINT CONTROL NUMBER: 08-AS-20231206111416

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: 115	DATE:	10/29/2025
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Executive Director, Kim Stratman		TIME COMPLETED:	01:50 PM

ALLEGATION(S):

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Staff did not maintain the facility clean
Staff did not meet resident's hygiene needs
Staff did not receive required training

INVESTIGATION FINDINGS:

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On October 29, 2025, Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced complaint visit to deliver investigative findings for the allegations listed above. LPA met with Executive Director Kim Stratman to present the investigative findings.

The Department’s investigation included a facility tour, record review, and interviews with staff and external sources.

On December 6, 2023, Community Care Licensing (CCL) received a complaint alleging that staff did not maintain the facility in a clean condition. Specifically, it was alleged that staff failed to clean Resident 1’s (R1’s) bathroom, which had feces on the floor and toilet, and that R1 tracked the feces from the bathroom into other areas of the room. Specific details regarding the date and time of the incident were not disclosed during the investigation.
(Continue at LIC9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20231206111416

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: 10/29/2025

NARRATIVE

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(continue from LIC9099)

A review of the housekeeping schedule indicated that R1 required full housekeeping assistance. Interviews with staff revealed that they cleaned R1’s room each morning, and when caregivers observed feces on the floor following an incontinence episode, they immediately contacted housekeeping for cleaning. Interviews with staff, residents, and external sources disclosed no concerns regarding the cleanliness, organization, or odor of resident rooms or other facility areas.

R1’s responsible party did not express concerns about staff maintaining R1’s hygiene or keeping the room clean and odor-free. During a visit conducted on December 11, 2023, twelve (12) rooms, including R1’s, were inspected and observed to be clean, free from clutter, and without unpleasant odors. No dirty or soiled clothing was observed, and incontinence products were sealed in plastic bags awaiting housekeeping pickup.

Staff interviews indicated that due to R1’s medical condition, frequent loose bowel movements occurred, requiring increased cleaning to meet R1’s needs. No violations were observed during the visit. There was insufficient evidence to support this allegation.

It was also alleged that staff did not meet R1’s personal hygiene needs, specifically that staff failed to fully clean R1 during incontinence care. Specific details regarding the alleged incident were not disclosed during the investigation. A review of R1’s medical records and service care plan indicated that R1 required assistance with all activities of daily living, including incontinence care.

During interviews, staff stated that R1 received incontinence care every two hours or more frequently as needed due to R1’s loose bowel movements. Staff also reported that R1 followed a predictable routine, and they were aware that incontinence care was typically required after meals. A review of the shower schedule indicated that R1 received two showers per week, or more often when necessary, following bowel movements that required more extensive cleaning. Interviews with residents and external sources did not disclose concerns regarding incontinence care. There was insufficient corroborating evidence to support this allegation.

(Continue at LIC9099C)

SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 08-AS-20231206111416

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: 10/29/2025

NARRATIVE

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(Continue from LIC9099C)

Lastly, it was alleged that staff did not receive proper training, specifically regarding how to safely transfer or reposition R1, and that caregivers lacked the necessary training to meet residents’ needs. Interviews with staff, residents, and external sources did not reveal concerns regarding staff training. A review of training records for five (5) randomly selected employees showed no violations of Title 22 regulations; all staff had completed the required training.

Additionally, in response to concerns raised by an external source, in-service training was provided to all staff during the time period of the complaint. Topics included: elopement prevention, safe use of transfer lifts, caring for residents with dementia, hospice care coordination, medication safety, Parkinson’s awareness, importance of hydration and nutrition in the elderly, fall prevention, music therapy for dementia care, behavioral management, and care for residents who are hearing or visually impaired.
Interviews with R1’s responsible party did not reveal any concerns regarding staff training or competency. Staff consistently reported having the necessary tools and skills to provide appropriate care and supervision to meet residents’ needs. There was no corroborating evidence to support this allegation.
Based on the investigation, including record reviews and interviews with staff, residents, and external sources, there was insufficient evidence to substantiate the allegations. Therefore, the allegations are deemed unsubstantiated.

An exit interview was conducted with the Executive Director. A copy of this report and the Licensee Appeal Rights (LIC 9058 03/22) were provided at the conclusion of the meeting.

SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2025

LIC9099 (FAS) - (06/04)

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