374603752-12-19-2022-08-AS-SJAB-CMJ2GA-20221227162249

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603752
Report Date: 12/16/2022
Date Signed: 12/19/2022 08:16:06 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
03/24/2021 and conducted by Evaluator Debbie Correia

COMPLAINT CONTROL NUMBER: 08-AS-20210324133204

FACILITY NAME:	ISLAND GROVE GUEST HOME II		FACILITY NUMBER:	374603752
ADMINISTRATOR:	RAMIREZ, CARMINDA		FACILITY TYPE:	740
ADDRESS:	12624 WILLOW ROAD		TELEPHONE:	(619) 454-3166
CITY:	LAKESIDE	STATE: CA	ZIP CODE:	92040
CAPACITY:	12	CENSUS: 10	DATE:	12/16/2022
		UNANNOUNCED	TIME BEGAN:	02:40 PM
MET WITH:	Administrator Carmi Ramirez		TIME COMPLETED:	03:25 PM

ALLEGATION(S):

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Lack of supervision.

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 Carmi Ramirez to whom the reason for the visit was explained.

The Department’s investigation consisted of staff, and outside source interviews. The investigation also consisted of facility records and a resident records review.

It was alleged that staff neglect resulted in Resident1 (R1) (See LIC 811 Confidential Names List) eloping from the facility on March 20, 2021 at approximately 4:20 pm. An Outside Source (OS1) revealed R1 was wintessed walking alone nearing a main road and OS1 called the police for a welfare check. The facility self-reported R1 was unable to communicate to the police the location of the facility, and R1’s contact and residency information per the police data base had not been updated and, subsequently, R1 was taken to the wrong facility and then taken to Grossmont Hospital. OS1 also revealed R1’s Power of Attorney (POA) was notified by the Hospital of R1’s location. OS1 then notified the facility and facility staff picked up R1 and they returned to the facility at approximately 6:30 pm that same day.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie Correia	TELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022

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-20210324133204

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 01/31/2023 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. Additional staff shall be employed as necessary...and house cleaning, laundering maintenance of buildings, equipment and grounds.	1 2 3 4 5 6 7	Administrator Ramirez will seek CCL approved vendor training regarding the care and supervision of residents experiencing cognitive issues, and conduct an extensive review of all resident records to determine level of care. Administrator will provide CCL proof of training by POC due date.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not ensure an appropriate supervision or plan to meet the needs for (R1) one out of nine residents. This posed an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie Correia	TELEPHONE: (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 3

Control Number 08-AS-20210324133204

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
	VISIT DATE: 12/16/2022

NARRATIVE

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A staff (S1) interview revealed the facility sits on a large piece of land and R1 often walked within the facility grounds, usually accompanied by other residents, but sometimes alone, without any past issues. LPA observed the facility grounds during a facility tour. The interview with S1 also revealed, when R1 was picked up by the Sheriff, R1 was still on the facility’s land. An interview with OS1 revealed, prior to moving into the facility, R1 resided in a Skilled Nursing Facility (SNF) and had begun to show signs of confusion and wandering behaviors. A review of facility records revealed R1 was deemed not fit or allowed to leave the facility unassisted. Facility records revealed R1 enjoyed walking along the facility grounds but would have to be reminded to avoid long walks without being accompanied by staff.

Based upon interviews conducted, records reviewed, and observations the above allegation is substantiated. This finding means that the preponderance of the evidence standard has been met and the allegations is valid. Deficiency is cited in accordance with California Code of Regulations, Title 22, Division 6, Chapter 8 and noted on the attached LIC 9099-D.

LPA Correia conducted an exit interview with Administrator Carmi Ramirez, A copy of the Complaint Investigation Report (LIC 9099) and Licensee Rights (LIC 9058 01-2016 03/2022) were provided to Administrator Carmi Ramirez and signature below confirms receipt of the documents.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie Correia	TELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022

LIC9099 (FAS) - (06/04)

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