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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603750
Report Date: 03/26/2024
Date Signed: 03/27/2024 10:23:44 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
10/31/2022 and conducted by Evaluator Natasha Persaud
COMPLAINT CONTROL NUMBER: 08-AS-20221031133222
FACILITY NAME:VILLA LORENAFACILITY NUMBER:
374603750
ADMINISTRATOR:COLLADO JR, JOSEFACILITY TYPE:
740
ADDRESS:14740 VIA FIESTATELEPHONE:
(858) 583-8480
CITY:SAN DIEGOSTATE: CAZIP CODE:
92127
CAPACITY:85CENSUS: DATE:
03/26/2024
UNANNOUNCEDTIME BEGAN:
05:31 PM
MET WITH:Memory Care Director, Marie Lou FikingasTIME COMPLETED:
06:30 PM
ALLEGATION(S):
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-Facility does not have adequate staffing to meet resident's needs
-Facility is malodorous
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit to conclude the investigation regarding the above-mentioned allegations. LPA met with Executive Director, Jose Collado Jr. and Memory Care Director, Marie Lou Fikingas.

During the investigation, the facility was briefly toured, records reviewed, and interviews conducted with staff, residents, and outside sources. It was alleged the facility does not have adequate staffing to meet the residents’ needs in the memory care unit. A review of staffing schedules indicated sufficient staffing. Staff interviews confirmed the facility had sufficient staffing. Staff also stated if a staff member calls out then the existing staff will work over one (1)-two (2) hours or a manager will assist. The facility will also use staff from their assisted living portion of the facility when necessary. The Executive Director’s (ED) interview confirmed the facility had sufficient staffing. ED also stated the facility does not use a registry for staffing, even though they have one on file to call if needed. ED stated if staff call out three (3) hours prior to their shift then a manager will cover the shift. Continued on an LIC 9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024
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-20221031133222
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: VILLA LORENA
FACILITY NUMBER: 374603750
VISIT DATE: 03/26/2024
NARRATIVE
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If staff call out for less than three (3) hours, then the staff already working will stay over for approximately one (1) to two (2) hours as needed. ED expressed staff have not complained and they all work together as family. The ED explained there were a couple of unforeseen circumstances that came about with staff not being present due to family emergencies. However, all shifts were covered.

Resident interviews expressed their needs are met and when they call for assistance, it’s received. The Resident Service Director (RSD) also confirmed the facility has sufficient staffing. The RSD explained the memory care unit has one (1) lead; four (4) caregivers; one (1) med tech; one (1) activity director. The Memory Care Director (MCD) also confirmed the memory care unit has sufficient staffing. Outside source interviews revealed the facility had insufficient staffing and addressed the issue with the MCD. On 10/29/22 the MDC responded to the outside source in writing and explained during this time a Medication Technician had a medical emergency and another care staff had a death in their family. However, services were not interrupted for the residents. The facility always ensured sufficient staff were present to meet the residents’ needs.

It was also alleged the facility was malodorous in the memory care unit. On 11/08/22, LPA observed the memory care unit, it was clean and odor free. Later in the visit, LPA was out in the common area and observed a strong feces odor. There was a resident sitting in a chair in the common area that fell asleep, sitting up in the chair. The resident had a bowel movement in their incontinent briefs. Staff interviews confirmed that residents were unable to alert staff when they have a bowel movement due to their Major Neurocognitive Disorder. Staff interviews revealed they check the residents every two (2) hours but if they smell the resident, they change their briefs immediately. The MCD also confirmed a specific resident likes to fall asleep in the common area and they have bowel movements, while in the common area. The MCD also stated staff check residents every two (2) hours or sooner if a smell was observed.

The ED, RSD, and MCD all confirmed there were no odors in the memory care unit. The Maintenance Director’s interview confirmed there were no odors, and the carpets were shampooed every two (2) weeks. The housekeeper’s interview also confirmed there were no odors but sometimes a resident has a bowel movement on themselves and that can cause the common area to smell. However, once observed, the caregivers change the residents.

During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegation. The allegation was deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) was provided to Memory Care Director, Marie Lou Fikingas whose signature below confirms receipt of these rights.

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024
LIC9099 (FAS) - (06/04)
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