374603715-4-5-2024-08-AS-SJAB-D4KMEF-20240422093239

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603715
Report Date: 04/04/2024
Date Signed: 04/05/2024 07:33:17 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 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
05/16/2023 and conducted by Evaluator Daniel Pena

COMPLAINT CONTROL NUMBER: 08-AS-20230516113325

FACILITY NAME:	HARBORVIEW SENIOR ASSISTED LIVING		FACILITY NUMBER:	374603715
ADMINISTRATOR:	SETTINERI, JEFFREY		FACILITY TYPE:	740
ADDRESS:	2360 ALBATROSS STREET		TELEPHONE:	(619) 233-8382
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92101
CAPACITY:	30	CENSUS: 26	DATE:	04/04/2024
		UNANNOUNCED	TIME BEGAN:	03:46 PM
MET WITH:	Genoveva Guerrero, Manager		TIME COMPLETED:	04:20 PM

ALLEGATION(S):

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Lack of supervision resulting in resident on resident abuse

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Daniel Pena conducted an unannounced visit to conclude a complaint investigation and deliver findings regarding the above-mentioned allegation. LPA was met by Genoveva Guerrero, Manager, and was granted entry into the facility. LPA met with Ms. Guerrero and discussed the purpose of the visit.

On 5/16/23, the Department received this complaint alleging, lack of supervision resulted in resident-on-resident abuse. Investigation consisted of interviews with pertinent residents, staff, and outside sources, record review, and LPA observations. Per an outside source, during the evening of 5/12/23, Resident 1 (R1) and other residents were in the dining room eating dinner. Resident 3 (R3) left the table to get a drink but was coming right back. Resident 2 (R2) came up and pulled out the chair where R3 had been sitting. R1 told R2 someone was sitting in that chair. R2 got mad and wouldn't go find another despite there were many open ones available. R1 stood up to get staff and R2 grabbed R1’s arm. R1 pulled away and had taken three steps when R2 hit R1 on the back with an open hand.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024

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-20230516113325

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: HARBORVIEW SENIOR ASSISTED LIVING	FACILITY NUMBER: 374603715
	VISIT DATE: 04/04/2024

NARRATIVE

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Staff 1 (S1) arrived at the area and separated R1 and R2 and documented the event on an Incident Report. R1 complained of pain the next day but it subsided later that evening. Staff interviews indicated R1 received a fingerprint size bruise on their shoulder. The residents and others in the area were contacted for their observation. Most of the residents contacted had Dementia diagnoses and were unable to provide statements. R1 provided their account which is consistent with the allegation reported to CCLD. R2 provided a statement saying they were sorry for striking R1. R3 was interviewed and said they did not see the incident. When asked, R3 said they never witnessed any resident strike another resident during the time they lived at the facility. LPA contacted an outside agency regarding the incident. LPA asked the outside source if they observed concerns with a lack of supervision at the facility. The outside source reviewed their records and found no complaints or related visits regarding a lack of supervision.

Records were reviewed, including staffing schedules. LPA found no evidence of staff shortages. Per Staff 2’s (S2) interview and staffing level record review, there were three staff working on the day of the incident. S2 said the shift was fully staffed. S2 conducted a post-action review of the incident and did not identify lack of supervision as a contributing factor. Per S2, S1 was in the dining area at the time of the incident. S2 said the altercation happened quick but S1 was able to respond and address it immediately. LPA asked S2 about the Incident Report submitted to CCLD. The report referenced counseling was provided. S2 said the term counseling referred to communication/training regarding R2’s updated care plan was disseminated to all staff. S2 said R2’s care plan was modified in response to R2’s change in behavior.

LPA interviewed S1. S1 said they were in the area when the incident occurred. S1 witnessed R2 squeeze the area of R1’s arm. S1 observed no immediate markings but said a bruise appeared on R1, 2-3 days later. S1 was in the kitchen when they heard R1 yell. S1 responded to the scene immediately and redirected the two residents. S1 said they asked residents in the area what they observed but none of the residents reported seeing anything. S1 said neither resident required one-on-one supervision or had a history of aggressive behavior. S1 prepared the LIC624 report documenting the incident.

The Department has investigated the allegation that lack of supervision resulted in resident-on-resident abuse. Based upon interviews with residents, staff, and outside sources, no corroboration or information was obtained to support the allegation. No evidence was obtained to prove the incident occurred due to a lapse in supervision by staff. The Preponderance of Evidence standard was not met. Therefore, the allegation is Unsubstantiated.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20230516113325

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: HARBORVIEW SENIOR ASSISTED LIVING	FACILITY NUMBER: 374603715
	VISIT DATE: 04/04/2024

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	An exit interview was conducted with Ms. Guerrero and a copy of this report was provided to Ms. Guerrero whose signature below confirms receipt of copies of this report and Licensee Rights (LIC 9058).

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024

LIC9099 (FAS) - (06/04)

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