374603788-11-8-2022-08-AS-JRAE-CNLNWK-20230131094938

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603788
Report Date: 11/08/2022
Date Signed: 11/08/2022 04:36:43 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 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
08/24/2022 and conducted by Evaluator Renita Hall

PUBLIC

COMPLAINT CONTROL NUMBER: 08-AS-20220824090957

FACILITY NAME:	LOVING HANDS SENIOR CARE		FACILITY NUMBER:	374603788
ADMINISTRATOR:	WILDFONG, MARIA		FACILITY TYPE:	740
ADDRESS:	3245 STAR ACRES DRIVE		TELEPHONE:	(619) 303-3862
CITY:	SPRING VALLEY	STATE: CA	ZIP CODE:	91978
CAPACITY:	6	CENSUS: 2	DATE:	11/08/2022
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Maria Ibisate Wildfron and Gloria Fuentes		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff hits resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Renita Hall and Interim Assistant Program Administrator (IAPA), Icela Estrada, conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegation. LPA and IAPA were greeted by Staff Gloria Fuentes, identified themselves, and were allowed into the facility. Licensee/Administrator, Maria Wildfong was not available during the visit.

The Department’s investigation consisted of interviews with staff, outside sources, residents, and review of records. It was alleged that staff hit resident #1 (R1). A review of records revealed that R1 was diagnosed with severe dementia and was non-ambulatory. R1’s Profile Sheet noted R1 was “not able to comprehend, not able to speak for himself”. IAPA and LPA attempted to interview R1 but R1 was unresponsive.

See continuation form LIC9099-C

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: John Rante	TELEPHONE: (619) 767-2330
LICENSING EVALUATOR NAME: Renita Hall	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2022

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-20220824090957

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: LOVING HANDS SENIOR CARE	FACILITY NUMBER: 374603788
	VISIT DATE: 11/08/2022

NARRATIVE

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Interview with staff #1 revealed R1 was on hospice and recently has been very agitated and combative. Staff #1 described how R1 kicks and hits them while they provide incontinence care or while they change R1. Staff #1 denied hitting R1 or any other resident. Interview with staff #2 confirmed R1 is on hospice and can be combative while they provide care. Staff #2 also denied hitting R1 or observing any other staff hitting R1 or other residents. Interview with resident #2 revealed R1 has declined in health and R2 misses hanging out with their friend. During the interview, R2 described R1 as a changed person who is aggressive and combative with staff. R2 denied observing staff hitting R1 or any other resident. R2 described staff as kind and sweet. Interview with administrator revealed that R1 has declined in health and was on hospice. Resident has passed as of 11/05/2022.

This Department has investigated the allegation that staff hit resident and has found that the preponderance of the evidence was not met; therefore, the allegation is deemed unsubstantiated.

An exit interview was conducted and a copy of this report along with the Licensee Rights (LIC 9058) were provided to Maria Ibisate Wildfong. Her signature on this form confirms receipt of the documents.

SUPERVISOR'S NAME: John Rante	TELEPHONE: (619) 767-2330
LICENSING EVALUATOR NAME: Renita Hall	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2022

LIC9099 (FAS) - (06/04)

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