374603713-10-25-2023-08-AS-DNGN-CWY2J3-20231025172541

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603713
Report Date: 10/25/2023
Date Signed: 10/25/2023 05:26:13 PM

Document Has Been Signed on 10/25/2023 05:26 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:	PARKVIEW MEMORY CARE AT PARADISE VILLAGE		FACILITY NUMBER:	374603713
ADMINISTRATOR:	AGUILAR, GEOVANNI		FACILITY TYPE:	740
ADDRESS:	735 ARCADIA AVENUE		TELEPHONE:	(619) 475-5040
CITY:	NATIONAL CITY	STATE: CA	ZIP CODE:	91950
CAPACITY:	70	CENSUS: 59	DATE:	10/25/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Executive Director Geovanni Aguilar and Resident Services Director Tatiana Soltero		TIME COMPLETED:	05:35 PM

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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Geovanni Aguilar and Resident Services Director Tatiana Soltero.

Today's visit was in response to two (2) LIC624 Incident Reports and two (2) SOC341 Reports of Suspected Dependent Adult/Elder Abuse, which licensee self-submitted to the CCLD San Diego Regional Office on 09/08/2023. The reports described alleged personal rights violations committed by Staff #1 (S1) against Resident #1 (R1) and Resident #2 (R2) on 09/05/2023, and which had since come to the licensee’s attention. [See LIC 811 Confidential Names List for a description of select person identifiers used in this report].

During today’s visit, LPA performed a facility tour and welfare check on R1 and R2, finding that both were safe. LPA also collected copies of pertinent care records and interviewed multiple relevant staff.

According to R1’s latest LIC602 Physician’s Report (dated 05/09/2023): R1 was diagnosed with “senile degeneration of the brain / dementia.” According to R2’s latest LIC602 Physician’s Report (dated 04/11/2023): R2 was diagnosed with “expressive language disorder” and “other unspecified disorders of the brain.” Manager and staff interviews unanimously showed that both R1 and R2 were cognitively-impaired as part of their baseline condition. LPA likewise observed that neither R1 nor R2 had the memory skills or verbal skills to be reliable interviewees.

[CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

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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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: PARKVIEW MEMORY CARE AT PARADISE VILLAGE	FACILITY NUMBER: 374603713
	VISIT DATE: 10/25/2023

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[CONTINUED FROM LIC 809]

Staff interviews, corroborated by time and date-stamped records, showed: During the evening of 09/05/2023, R1 did not want to receive personal care from S1. S1 used their own hands to physically restrain R1’s hands. S1 then used their fingers to pinch R1’s neck and spoke disrespectfully about R1 in front of them, towards Staff #2 (S2), who witnessed the above. Also during the evening of 09/05/2023, R2 did not want to receive bathroom assistance from S1. R2 was in their wheelchair and grabbed onto the doorframe of their bathroom in protest. Rather than stop, S1 continued to pull on R2’s wheelchair handles until R2 slid out of the wheelchair and onto the floor. This latter act was witnessed by S2 and Staff #3. Staff #4 did not witness the moment R2 slid out, but responded post-incident and corroborated that they personally helped R2 up off the floor. R1 and R2 did not suffer observable injuries from the incident.

Records and staff interviews unanimously showed: Licensee became are of the above incidents on 09/06/2023, and immediately placed S1 on administrative leave pending further investigation. The same day S1 was placed on leave, they resigned from employment. Licensee’s own internal investigation concluded that S1 had committed the above alleged actions.

A preponderance of evidence exists to show that during the incidents in question, licensee’s staff (S1) did not ensure that residents in care (R1 and R2) were free from humiliation and physical abuse. One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the licensee.

An exit interview was conducted with Aguilar, to whom a copy of this report, the LIC 809-D, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/25/2023 05:26 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: PARKVIEW MEMORY CARE AT PARADISE VILLAGE	FACILITY NUMBER: 374603713
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/25/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/26/2023 Section Cited CCR 87468.1	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities: “(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from…humiliation…abuse…” This requirement was not met, as evidenced by:	1 2 3 4 5 6 7	Per staff and manager interviews: S1’s employment ended on 09/06/2023, resolving the immediate risk. Licensee agreed to retrain its direct care team at large on: a) Resident’s Personal Rights, b) Mandated Reporting Requirements, and c) How to correctly manage behaviors and refusal of care for residents diagnosed with dementia. Licensee agreed to submit a copy of the handouts used and the training sign-in sheet to LPA, by 11/24/2023.
	8 9 10 11 12 13 14	Based on records and interviews, licensee’s staff (S1) did not ensure that 2 of 59 residents (R1 and R2) were free from humiliation and abuse, which posed an immediate health, safety, personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

LIC809 (FAS) - (06/04)

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