374603699-3-16-2023-08-AS-JRAE-CQEV2T-20230330160339

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603699
Report Date: 03/16/2023
Date Signed: 03/16/2023 12:54:19 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/11/2022 and conducted by Evaluator Iby Strong

PUBLIC

COMPLAINT CONTROL NUMBER: 08-AS-20220111120946

FACILITY NAME:	SAPPHIRE LAKE SAN MARCOS		FACILITY NUMBER:	374603699
ADMINISTRATOR:	MATIC, VICTORIA		FACILITY TYPE:	740
ADDRESS:	839 LA TIERRA DRIVE		TELEPHONE:	(760) 471-1157
CITY:	SAN MARCOS	STATE: CA	ZIP CODE:	92078
CAPACITY:	6	CENSUS: 6	DATE:	03/16/2023
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Administrator Victoria Matic		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Resident developed pressure injuries while in care due to neglect
Staff did not protect client from self-neglect

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to deliver findings in the above complaint allegations. LPA identified herself and discussed the purpose of the visit with Administrator Victoria Matic.

On January 11, 2022, Community Care Licensing (CCL) received a complaint alleging Resident 1 (R1) developed pressure injuries while in care due to neglect and staff did not protect R1 from self-neglect.

During investigation, LPA Strong collected pertinent resident records as well as facility documentation and conducted interviews. Based on R1’s Physician Report dated November 8, 2021, R1 can communicate needs, is non-ambulatory and requires assistance with bathing, grooming and toileting. Additionally, R1’s Needs and Services Plan dated June 16, 2021, states R1 is at risk of skin breakdown and has periods of urinary incontinence requiring a foley catheter

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: John Rante	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Iby Strong	TELEPHONE: (619) 481-0846
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

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 08-AS-20220111120946

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: SAPPHIRE LAKE SAN MARCOS	FACILITY NUMBER: 374603699
	VISIT DATE: 03/16/2023

NARRATIVE

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According to allegations, facility staff were only changing resident’s incontinence undergarment twice per day, resulting in pressure injuries but no specific time frame was provided. According to records collected, R1 moved into facility on November 8, 2021, and was sent to the hospital on January 6, 2021, but did not return to facility after hospitalization. According to interview with Administrator, R1 was refusing care since move-in date. Interview with staff present revealed resident was being changed multiple times per day but R1 did not allow staff to provide care multiple times per week. Records collected revealed that R1 was admitted to facility with a pressure injury, and such was documented as of November 9, 2021, by staff. Interview with outside source revealed that there was no indication that staff present would not change resident multiple times per day. Records also revealed that R1 was being treated for a pressure injury by a Home Health Agency (HHA) as of November 18, 2021. Records also corroborated that HHA was providing wound care on a weekly basis from November 18, 2021, until the week of January 4, 2022.

It was also alleged that staff did not protect R1 from self-neglect. Interview with Administrator revealed that multiple agencies were advised of R1’s care refusal including R1’s Primary Care Provider (PCP), Home Health Agency (HHA) and responsible party (RP). Interview with staff present corroborated that PCP, HHA and RP were informed of R1’s care refusal. Interview with outside source revealed R1 was refusing care from HHA as well, including refusing catheter care. Outside source records corroborated that PCP was aware of R1 refusing care. Records collected corroborated that all agencies involved in R1’s care were aware of care refusal. Interview with outside source revealed that an outside agency and facility Administrator were attempting to relocate R1 in efforts to prevent R1 from self-neglect. Records collected corroborated that outside agency was attempting to find R1 different placement.

Based on LPA's internal interviews, outside source interviews, and record reviews there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegations are unsubstantiated. An exit interview was conducted with Administrator Victoria Matic, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.

SUPERVISOR'S NAME: John Rante	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Iby Strong	TELEPHONE: (619) 481-0846
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

LIC9099 (FAS) - (06/04)

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