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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603643
Report Date: 02/23/2023
Date Signed: 02/23/2023 06:37:04 PM


Document Has Been Signed on 02/23/2023 06:37 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



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: 152DATE:
02/23/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Executive Director Kim StratmanTIME COMPLETED:
05:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management visit. LPA was welcomed by and identified himself to Receptionist Sharmaine Ta. LPA then met and discussed the purpose of the visit with Executive Director Kim Stratman.

Today's visit was in response to a self-reported AWOL (absent without leave event) involving Resident #1 (R1), received in the San Diego Regional Office on 02/17/2023 [see LIC 811 Confidential Names List for a description of person identifiers used in this report]. LPA performed facility tour / welfare check, collected records, and interviewed R1 and staff.

Per the LIC624 Incident Report which licensee submitted to CCLD: R1 lived in the facility’s memory care wing. On 02-13-2023, a concerned citizen observed R1 "a few blocks away" from the facility and phoned 911. Police found R1 unharmed/uninjured. Police notified R1’s responsible party and facility staff around 8:30 AM and then brought R1 back to the facility around 9:10 AM. Facility staff last saw R1 inside the facility around 7:00 AM. Staff did not observe R1 leave the facility and were initially unaware that R1 was absent.

CCLD visually verified R1 was unharmed/uninjured. Due to their baseline memory loss, R1 was not able to participate as a reliable historian/interviewee. Per their latest LIC602 Physician’s Report, R1 was diagnosed with dementia and “needs assistance” to leave the facility.

Per time and date stamped progress notes, personnel records, staff interviews, and licensee’s own internal investigation, during the incident in question, security camera footage showed Staff #1 (S1) exited the memory care wing while pushing a cart. S1 momentarily unlocked/deactivated the alarmed door to leave. R1 followed behind S1, before the door closed and re-locked, but S1 was unaware of this. R1 then exited the facility's lobby without other staff noticing. [CONTINUED ON LIC 809-C]
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/23/2023 06:37 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: ST. PAUL'S PLAZA
FACILITY NUMBER: 374603643

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/23/2023
Section Cited

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87466 Observation of the Resident: “The licensee shall ensure that residents are regularly observed…” This requirement was not met, as evidenced by:
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Per personnel records and staff interviews, licensee performed written coaching with S1 on 02-14-2023 regarding the incident. Per staff interviews and LPA observation, licensee added signs to both sides of the memory care wing exit door to remind visitors/staff to look behind them before exiting. These actions resolve the deficiency.
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Based on records and interviews, the licensee did not ensure that 1 of 152 residents in care (R1) was observed, which posed a potential safety risk to persons in care.
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Type B
02/23/2023
Section Cited

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1569.317 Absentee Notification Plan for Missing Residents: “Every residential care facility for the elderly…shall, for the purpose of addressing issues that arise when a resident is missing from the facility, develop and comply with an absentee notification plan…”
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Per training records and staff interviews, on 02-17-2023, licensee retrained its staff at large on the facility's Elopement/Missing Resident policy. This action resolves the deficiency.
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This requirement was not met, as evidenced by: Based on records and interviews, the licensee did not comply with its absentee notification plan for 1 of 152 residents in care (R1), which posed a potential 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.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: ST. PAUL'S PLAZA
FACILITY NUMBER: 374603643
VISIT DATE: 02/23/2023
NARRATIVE
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[CONTINUED FROM LIC 809]

According to the facility’s Elopement Policy and Procedure, when a resident cannot be located, staff are required to call 911 and the resident’s responsible party, not more than 15 minutes after beginning the search. This expectation was reiterated in R1's Care Plan. Multiple staff interviews corroborated that direct care staff became aware of R1’s absence and began looking for R1 at least 30 minutes before the police first called facility staff (and not other way around).

Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). Plans of Correction were jointly developed with the licensee. An exit interview was conducted with Stratman, to whom a copy of this report, the LIC 809-D, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023
LIC809 (FAS) - (06/04)
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