374603767-4-22-2024-08-AS-LTEZ-D4U249-20240430170333

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603767
Report Date: 04/22/2024
Date Signed: 04/22/2024 11:53:41 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
09/15/2023 and conducted by Evaluator Renita Hall

COMPLAINT CONTROL NUMBER: 08-AS-20230915162022

FACILITY NAME:	UTOPIA HAVEN		FACILITY NUMBER:	374603767
ADMINISTRATOR:	ATANQUE-HAVERLY, HANNAH		FACILITY TYPE:	735
ADDRESS:	1755 CIRCO DEL CIELO DRIVE		TELEPHONE:	(619) 227-7082
CITY:	EL CAJON	STATE: CA	ZIP CODE:	92020
CAPACITY:	4	CENSUS: 4	DATE:	04/22/2024
		UNANNOUNCED	TIME BEGAN:	11:37 AM
MET WITH:	Amber Agsaulio, House Manager		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not provide timely medical care
Staff did not attend to chnge in condition

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Renita Hall conducted an unannounced visit to deliver findings. LPA was allowed entry Lawrence Balangue, DSP and Amber Agsaulio, House Manager. LPA identified herself and disclosed the purpose of the visit and elements of the findings to the House Manager.

On September 15, 2023, the department received a complaint for the following allegations: Staff did not provide timely medical care and staff did not attend to change in condition. The Department did a facility tour, collected records, and conducted interviews.

A complaint was filed alleging that staff failed to provide timely medical care and did not attend to a change in condition for a resident with a history of pulling out their G-tube. The resident had a documented history of pulling out their G-tube, and records indicated that there were exception waivers for the resident's care. Documented history also indicated that Resident 1 (R1) had one-on-one care in the hospital where R1 would pull out the G-tube while in care.
Continued on 809C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Renita Hall
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2024

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 2

Control Number 08-AS-20230915162022

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: UTOPIA HAVEN	FACILITY NUMBER: 374603767
	VISIT DATE: 04/22/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The resident was also noted to have used protective gear such as a helmet, mittens, a custom manual wheelchair with a quick-release seat belt, and a neoprene protective body vest. Additionally, staff were trained on August 25, 2023, for wound care per discharge instructions for the resident.

Upon investigation, it was determined that the allegations were unsubstantiated. The resident's medical records were reviewed, and it was found that the staff had been following the care plan and had been providing the necessary medical attention to the resident promptly.

Furthermore, there was no evidence to suggest that staff had neglected the resident or failed to attend to a change in the resident's condition. All necessary measures were taken to ensure the resident's safety and well-being by the exception waivers and care plan.

In conclusion, based on the evidence gathered during the investigation, the allegations of failure to provide timely medical care and attendance to a change in condition for the resident were found to be unsubstantiated. A finding that is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

An exit interview was conducted and a copy of this report along with the Licensee Rights (LIC 9058) was provided to Amber Agsaulio, House Manager. Her signature on this form confirms receipt of the documents.

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Renita Hall
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2