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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603752
Report Date: 09/26/2024
Date Signed: 09/26/2024 11:06:30 AM

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
08/23/2024 and conducted by Evaluator Renita Hall
COMPLAINT CONTROL NUMBER: 08-AS-20240823150522
FACILITY NAME:ISLAND GROVE GUEST HOME IIFACILITY NUMBER:
374603752
ADMINISTRATOR:RAMIREZ, CARMINDAFACILITY TYPE:
740
ADDRESS:12624 WILLOW ROADTELEPHONE:
(619) 454-3166
CITY:LAKESIDESTATE: CAZIP CODE:
92040
CAPACITY:12CENSUS: 9DATE:
09/26/2024
UNANNOUNCEDTIME BEGAN:
10:02 AM
MET WITH:Paz Abbot, CaregiverTIME COMPLETED:
11:10 AM
ALLEGATION(S):
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Questionable deaths
Staff mismanaged residents' medications
Staff failed to meet the residents' needs
Staff unable to communicate with residents due to a language barrier.
untrained staff
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Renita Hall, conducted an unannounced visit to deliver findings regarding the above-mentioned allegations LPA was allowed entry by Paz Abbot, Caregiverr. LPA identified herself and disclosed the purpose of the visit and elements of the findings with the Caregiver.

The Department’s investigation consisted of interviews with staff, residents, outside sources, a review of records, and a tour of the facility. It was alleged that neglect by facility staff resulted in the questionable deaths of Residents #1-2 (R1-R2).

A review of records revealed R1 was admitted to the facility on September 12, 2020. R1 was non-ambulatory and required assistance with toileting, feeding, dressing, grooming, bathing, and incontinence care. R1 was confused/disoriented but was able to communicate their needs. Resident appraisal records noted that R1 was admitted to the facility with a wound on their buttocks.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Renita Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 08-AS-20240823150522
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: ISLAND GROVE GUEST HOME II
FACILITY NUMBER: 374603752
VISIT DATE: 09/26/2024
NARRATIVE
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On September 14, 2020, home health staff documented R1 had an unstageable pressure injury on their sacrum. R1 also had a stage 1 pressure injury to their left leg. Records indicated staff were educated on the importance of repositioning R1. R1 began receiving hospice services on October 3, 2020. A review of home health records noted that skilled medical professionals deemed the sacral pressure injury as a possible Kennedy Terminal Ulcer based on the rapid progression and location of the pressure injury. Per the National Institutes of Health, a Kennedy Terminal Ulcer is an unavoidable skin breakdown that occurs in some patients as part of the dying process. It often appears on the sacrum or coccyx. Interviews revealed conflicting statements regarding incontinence care and repositioning of R1. Interviews with outside medical professionals who visited the facility and observed R1 did not have concerns regarding neglect or unmet needs for R1. Additionally, there were no concerns regarding assistance with medication administration or mismanagement of R1’s medication. R1 passed away at the facility on October 13, 2020. According to the County of San Diego Certificate of Death, R1’s cause of death was listed as Alzheimer’s Disease.

A review of records revealed that R2 was bedridden and required assistance with all activities of daily living, including bathing, dressing, grooming, feeding, transferring, and incontinence care. R2 was diagnosed with a major neurocognitive disorder and was unable to communicate their needs. R2 began receiving hospice services from a hospice agency the day after being admitted to the facility. Interviews with staff indicated staff checked on R2 approximately every two hours to assist with repositioning and assisted R2 with incontinence care. Interviews with outside sources and records review revealed that R2 suffered multiple falls and continuous decline before entering the facility. Interviews with outside sources and outside medical professionals who visited the facility observed that R2 did not have concerns regarding neglect or unmet needs for R2. Additionally, there were no concerns regarding assistance with medication administration or mismanagement of R2’s medication. R2 passed away at the facility on October 10, 2020. R2’s cause of death was listed as Vascular Dementia and Cerebral Atherosclerosis. Outside source and residents interviewed regarding the language barrier, there are no concerns, and staff could communicate with residents in their preferred language.

Based on the investigation findings, the allegations made against the staff regarding: Questionable Deaths, Staff Mismanagement of Residents' Medications, Staff Failure to Meet Residents' Needs, Untrained staff, and Staff Unable to Communicate with Residents Due to a Language Barrier—are unsubstantiated. A finding that is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted with the director. A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided to the Caregiver and her signature on this report confirms receipt of the Licensee Rights.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Renita Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
08/23/2024 and conducted by Evaluator Renita Hall
COMPLAINT CONTROL NUMBER: 08-AS-20240823150522

FACILITY NAME:ISLAND GROVE GUEST HOME IIFACILITY NUMBER:
374603752
ADMINISTRATOR:RAMIREZ, CARMINDAFACILITY TYPE:
740
ADDRESS:12624 WILLOW ROADTELEPHONE:
(619) 454-3166
CITY:LAKESIDESTATE: CAZIP CODE:
92040
CAPACITY:12CENSUS: 9DATE:
09/26/2024
UNANNOUNCEDTIME BEGAN:
10:02 AM
MET WITH:Paz Abbot, CaregiverTIME COMPLETED:
11:10 AM
ALLEGATION(S):
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Uncleared adult
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Renita Hall, conducted an unannounced visit to deliver findings regarding the above-mentioned allegations LPA was allowed entry by Paz Abbot, Caregiver. LPA identified herself and disclosed the purpose of the visit and elements of the findings with the Caregiver.

On December 02, 2020, the department received a complaint that an uncleared adult working at the facility. An investigation was initiated following an allegation that an uncleared adult was working within the facility, potentially violating safety and regulatory protocols. Interviews were conducted with facility staff and other relevant individuals. A review of employee records, and clearance documentation to determine the status of the individual in question.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Renita Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 08-AS-20240823150522
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: ISLAND GROVE GUEST HOME II
FACILITY NUMBER: 374603752
VISIT DATE: 09/26/2024
NARRATIVE
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The investigation confirmed that the individual in question was not listed in the facility's clearance records. They did not possess the required background checks or clearance necessary for the unsupervised presence within the facility as a paid employee. The staff interviewed corroborated that the individual had been present in the facility without the proper clearance.

The allegation that an uncleared adult was an employee within the facility is substantiated as there is a preponderance of evidence to prove the alleged violation occurred. The individual was hired as a caregiver without the necessary background checks and approvals, which is a violation of Code Health and Safety Code section 1569.17 (e )(1). An exit interview was conducted; a copy of this report along with Licensee Appeal Rights LIC 9058 (REV 3/22) were provided to Paz Abbot and her signature confirms receipt of these documents.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Renita Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 08-AS-20240823150522
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: ISLAND GROVE GUEST HOME II
FACILITY NUMBER: 374603752
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/26/2024
Section Cited
HSC
1569.17(b)(1)
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b)All individuals subject to a criminal record review pursuant ....... shall prior to working, residing or volunteering in a licensed facility:
(1) Obtain a California clearance or a criminal record exemption as required by the Department
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Immediate Action: Ensure that the uncleared individual does not have access the facility until proper clearance is obtained. POC cleared 12/14/2020.
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This requirement was not met as evidenced by: Based on interview, records, and systems review, the licensee did not ensure Staff #1
had a CA criminal record clearance prior toworking or volunteering in the licensed facility which posed an immediate Health, Safety and Personal Rights Risk to person in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Renita Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5