374603714-11-21-2024-08-AS-LTEZ-DBE5DQ-20241126185219

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603714
Report Date: 11/21/2024
Date Signed: 11/21/2024 12:58:47 PM

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
10/28/2024 and conducted by Evaluator Iby Strong

PUBLIC

COMPLAINT CONTROL NUMBER: 08-AS-20241028134911

FACILITY NAME:	ACTIVCARE AT 4S RANCH		FACILITY NUMBER:	374603714
ADMINISTRATOR:	ALSOP, MARK		FACILITY TYPE:	740
ADDRESS:	10603 RANCHO BERNARDO ROAD		TELEPHONE:	(858) 485-8001
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92127
CAPACITY:	60	CENSUS: 53	DATE:	11/21/2024
		UNANNOUNCED	TIME BEGAN:	10:50 AM
MET WITH:	Executive Director Denise Notter		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Staff left resident on the floor after a fall

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Iby Strong conducted an unannounced complaint visit to deliver findings on the above-mentioned allegation. LPA met Executive Director Denise Notter and discussed the purpose of the visit.

On October 28, 2024, Community Care Licensing (CCL) received a complaint alleging staff left Resident 1 (R1) on the floor after a fall. Based on R1's Physician Report dated September 3, 2024, R1 can communicate need and is able to follow instructions. During the investigation, LPA Strong conducted interviews, and reviewed facility records.

According to the allegation on October 27, 2024, Resident 1 (R1) was observed to be crawling on the floor of the facility hallway after a fall and staff present left resident there an extended amount of time. Interview with staff present on the date of the incident revealed that Staff 1 (S1) was doing rounds at around 8:30pm, opened R1’s bedroom door and found R1 crawling on the floor.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Iby Strong	TELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024

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-20241028134911

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: ACTIVCARE AT 4S RANCH	FACILITY NUMBER: 374603714
	VISIT DATE: 11/21/2024

NARRATIVE

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According to S1, R1 had finished using the restroom independently and as S1 walked into R1’s room, R1 was found crawling out of the bathroom towards the front door. Based on Staff 2 (S2) statement, R1 was asked to stay in the same space to assess for injuries but R1 continued crawling towards the hallway. S2 revealed that during this time, both S1 and S2 had requested assistance from the Licensed Vocational Nurse (LVN) via walkie- talkie who arrived within 2 minutes. Interviews with S1, S2, and LVN corroborated that R1 did not fall, rather chose to crawl from one space to another and had no injuries. Additionally, records reviewed confirmed R1 has had other episodes of choosing to crawl rather than use their personal walking equipment. Interview with R1 confirmed that R1 does chose to crawl to the restroom and back to bed or chair. Interview with outside source revealed that there have been no instances observed where any resident is left unattended after a fall for an extended period.

Based on 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 Executive Director Denise Notter, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Iby Strong	TELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024

LIC9099 (FAS) - (06/04)

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