374603715-4-5-2024-08-AS-SJAB-D4TKJC-20240430075627

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603715
Report Date: 04/04/2024
Date Signed: 04/05/2024 07:34:09 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
05/25/2023 and conducted by Evaluator Daniel Pena

COMPLAINT CONTROL NUMBER: 08-AS-20230525113628

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:	01:43 PM
MET WITH:	Genoveva Guerrero, Manager		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Licensee did not provide copy of admission agreement
Licensee did not safeguard residents' belongings
Licensee did not report resident's change in condition to responsible party

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Daniel Pena conducted an unannounced facility visit to conclude a complaint investigation regarding the above-mentioned allegations. LPA identified himself and discussed the purpose of the visit and complaint conclusion with Genoveva Guerrero, Manager.

On 5/25/2023, the Adult and Senior Care Regional Office received a complaint alleging; the licensee did not provide a resident’s representative with a copy of the admission agreement, did not safeguard a resident’s personal belongings and did not report a change in the resident’s condition to the representative. The Department’s investigation consisted of observations, interviews with pertinent staff and outside sources and facility record reviews.

It was alleged, Resident 1's (R1) representative was not given a copy of the Admission Agreement. Record review show the representative signed all required pages of the agreement. Staff interviews indicate that the representative refused a copy on the day they signed the agreement. An outside source

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-20230525113628

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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denied the representative refused to accept a copy. LPA confirmed with the outside source that the representative did receive a copy of the agreement but did not recall the date.

As to the allegation the facility did not safeguard a resident’s belongings, LPA found insufficient evidence to prove this claim. LPA obtained a copy of R1’s LIC621 Resident Personal Property and Valuables. The document contained no entries. Per staff interviews, R1 had no personal property when they moved in. An interview with staff indicated that a relative of R1 took with them a bracelet on the day R1 moved into the facility. Staff interviews and records refute that R1 had property when they were admitted to the facility. Outside sources said they did not contact law enforcement to report a theft of R1’s property.

Additionally, it was stated R1’s representative was not notified when R1 experienced a change in condition. Following two choking incidents which occurred in May 2023, an outside source claimed that the resident at times refused to attend medical appointments and would not go. The source stated that the resident also refused to be transported to the hospital following one of the choking incidents. The source stated that R1 would sign refusals of treatment but did not have the cognitive capacity. A review of R1’s records revealed appraisals and needs and services plans showing R1’s representative was notified when care plan changes were made.

The Department has investigated the above-mentioned allegations and obtained insufficient evidence to corroborate them. The Preponderance of Evidence standard was not met. Therefore, the allegations are Unsubstantiated.

An exit interview was conducted with Ms. Guerrero and a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to Ms. Guerrero and her signature on said documents confirms receipt of receiving them.

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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