374603643-4-30-2024-08-AS-LTEZ-D5SVXQ-20240531164954

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603643
Report Date: 02/07/2024
Date Signed: 04/30/2024 11:46:38 AM

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
12/08/2022 and conducted by Evaluator Renita Hall

COMPLAINT CONTROL NUMBER: 08-AS-20221208135517

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: 147	DATE:	02/07/2024
		UNANNOUNCED	TIME BEGAN:	02:08 PM
MET WITH:	Maria Sano, Assistant Administrator		TIME COMPLETED:	02:50 PM

ALLEGATION(S):

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Facility staff did not properly assist resident causing resident to fall and sustain an injury(ries).
Facility staff handled resident in a rough manner causing an injury(ries).
Facility staff did not provide incontinence care resulting in skin breakdown
Resident sustained unexplained injuries.
Facility staff did not serve resident dinner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Renita Hall conducted an unannounced visit to deliver findings. LPA was allowed entry by the Maria Sano, Assistant Administrator. LPA identified herself and disclosed the purpose of the visit and elements of the findings to the Assistant Administrator.

On December 08, 2022, The Department investigated the above-listed complaint allegations. The investigation consisted of a facility tour, interviews with staff and outside sources, and a records review.

Allegation 1: On March 25, 2019, Resident 1 (R1) was assisted by Staff 1 (S1) due to a fall. Immediate response was initiated, and R1 was immediately transported to a hospital via a 911 call, sutures were placed onto a two-inch laceration at R1's eyebrow. The complainant was interviewed regarding this fall. The complainant reported that they did not have a problem with this particular fall, or the staff’s response to the fall. The complainant reported that they included the fall on the complaint referral to add to the totality of falls and bruises sustained by R1 while residing at St. Paul’s Plaza, which has been over five years. The physician report noted that R1 had motor impairment with unstable gait and a history of falls.

Continued on 9099C Amended report to include dietary needs at 10:28 am on April 30,2024

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Renita Hall
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024

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-20221208135517

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: 02/07/2024

NARRATIVE

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Allegation 2: A video submitted by the complainant did not reflect the allegation of “yanking” or staff being “rough” causing an injury(ries) to R1. The video, was of a caregiver on 11/01/22 at 0456 hours removing the diaper from R1, who was lying on their back in bed. The caregiver pulls the diaper from underneath R1 until the diaper is pulled away from R1's body weight. Although the technique is questionable, it was not observed to be pulling or “yanking,” or any forceful action by the caregiver.

Allegation 3: The physician's report stated resident had impairment of bowel and bladder, continuous bed care with frequent repositioning, and a history of stage 2 pressure ulcer to sacrum. Care of Plan: Staff will check every 2 hours for continence and as needed. Staff training was conducted with the CNA caregiving staff on proper techniques for changing incontinence for residents.

Allegation 4: In regards to the unexplained injuries, it could not be determined how the injuries occurred. The St. Paul’s Plaza Executive Director and Director of Nursing were interviewed, as well as outside sources. The numerous photos also include two photos of R1's knees. The photos are not timestamped. The knees appear to be slightly red with possible light bruising. The “injuries” do not appear to be significant, if they are “injuries.”

Allegation 5: R1 required a special diet "thin liquid via straw, NTL via straw prn. Dietary changes due to pocketing food. R1 was to consume 75-100% of meals with no signs or symptoms of aspiration goal date was 03/08/2020. Residents interviewed confirmed they received three meals a day plus snacks. Staff interviewed stated that three meals per day are served plus snacks which included puree diets, mechanical diets, regular diets, and pescatarian diets. Certified Nursing Assistants (CNA's) served snacks to residents prepared by kitchen staff. There were no instances were staff did not provide R1 dinner.

Based on the investigation findings, it is concluded that the allegations: Facility staff did not properly assist resident causing resident to fall and sustain an injury(ries); Facility staff handled resident in a rough manner causing an injury(ries); Facility staff did not provide incontinence care resulting in skin breakdown; Resident sustained unexplained injuries; Facility staff did not serve resident dinner are unsubstantiated. A finding that is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted; a copy of this report along with Licensee Appeal Rights LIC 9058 (REV 3/22) were provided to the Assistant Administrator and her signature confirms receipt of these documents.

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Renita Hall
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024

LIC9099 (FAS) - (06/04)

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