374603671-5-10-2023-18-AS-JDHS-CU6PZ6-20230728114459

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603671
Report Date: 05/10/2023
Date Signed: 05/10/2023 02:54:59 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/02/2023 and conducted by Evaluator Tricia Danielson

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20230502105304

FACILITY NAME:	SAPPHIRE ESCONDIDO ESTATES		FACILITY NUMBER:	374603671
ADMINISTRATOR:	ALI NAGHIBI		FACILITY TYPE:	740
ADDRESS:	262 SILVERCREEK GLEN		TELEPHONE:	(760) 291-1202
CITY:	ESCONDIDO	STATE: CA	ZIP CODE:	92029
CAPACITY:	6	CENSUS: 6	DATE:	05/10/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Imelda "Amy" Santos, Caregiver Liz Rivera, Administrator		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Lack of care and supervision resulting in resident being injured

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Tricia Danielson and Kathleen Banrasavong arrived unannounced to the facility to initiate an investigation into the allegation listed above. LPAs met with Caregiver Imelda "Amy" Santos and explained the purpose of the visit. Administrator Liz Rivera was notified via telephone of LPA's visit and arrived a short time later.
During today's visit, LPA's toured the facility and interviewed one (1) staff, one (1) resident, and reviewed documentation pertinent to Resident #1 (R1) and Resident #2 (R2). Regarding the allegation "Lack of care and supervision resulting in resident being injured", it was alleged that R1 was left unsupervised which allowed them to hit R2 with a hairbrush several times. Review of R1's Physician's report indicated R1 can be verbally aggressive, can display inappropriate behavior at times, and is not at risk for self-abuse. Review of R1's Resident Appraisal indicated R1 is easily upset with behavioral outbursts especially around unfamiliar people and group activities may provoke an outburst as well. R1's Individual Service Plan revealed R1 displays paranoia, delusional thinking, agitation and anger at times related to their diagnosis. Records reviewed did not indicate R1 required direct supervision at any given time. (CONTINUED ON LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 782-4807
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023

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 18-AS-20230502105304

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SAPPHIRE ESCONDIDO ESTATES	FACILITY NUMBER: 374603671
	VISIT DATE: 05/10/2023

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	(CONTINUED FROM LIC9099) Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted and a copy of this report was provided along with LIC811- Confidential Names list.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 782-4807
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023

LIC9099 (FAS) - (06/04)

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