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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603752
Report Date: 12/16/2022
Date Signed: 12/19/2022 08:12:04 AM

Substantiated


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
12/08/2022 and conducted by Evaluator Debbie Correia
COMPLAINT CONTROL NUMBER: 08-AS-20221208092714
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:
12/16/2022
UNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Administrator RamirezTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Facility staff are not following Covid-19 safety protocols.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced visit to deliver investigative findings on the above listed complaint allegation. LPA was met and granted entry into the facility by Administrator Ramirez to whom was explained the reason for the visit.

The Department’s investigation consisted of outside source interviews and LPA observations.

It was alleged that staff are not following COVID-19 safety precautions An interview with an outside source (OS1) revealed that during a facility visit a staff member was not wearing a mask. LPA conducted an unannounced visit on December 14, 2022 to open the investigation in regard to the above listed allegation and observed the property owner in the facility not wearing a mask.

A deficiency was cited Per Title 22, Division 6, Chapter 8 of the California Code of Regulations (see LIC9099-D). An exit interview was conducted with Administrator Ramirez to whom a copy of this report and the Licensee appeal Rights (LIC9058) were provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022
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 2
Control Number 08-AS-20221208092714
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: ISLAND GROVE GUEST HOME II
FACILITY NUMBER: 374603752
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/23/2023
Section Cited
CCR
87468.1
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87468.1 Personal Rights of Residents in All
Facilities: “(a) Residents in all residential care
facilities for the elderly shall have all of the
following personal rights: (2) To be accorded
safe, healthful…accommodations.”
This requirement was not met, as evidenced by:
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Caregiver agreed to conduct an internal in-service training on the most current guidance regarding facial coverings.Administrator will submit the training-sign in sheet to LPA by the POC due date.
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Based on LPA observations, licensee did not accord residents specific required safe and healthful accommodations. This posed a potential health risk to 6 of 6 residents 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.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2