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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603815
Report Date: 03/20/2024
Date Signed: 03/20/2024 06:35:14 PM

Document Has Been Signed on 03/20/2024 06:35 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:SOLARIS 36FACILITY NUMBER:
374603815
ADMINISTRATOR:ARCA, LUCIAFACILITY TYPE:
740
ADDRESS:14536 GARDEN RDTELEPHONE:
(858) 842-4246
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY: 6CENSUS: 5DATE:
03/20/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:House Manager Joseph Bisco and Site Manager Anafe RiveraTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with House Manager Joseph Bisco. LPA then met with Site Manager Anafe Rivera, who arrived later during the visit.

Today's visit was in response to an LIC624 Incident Report, which Licensee self-submitted to the CCLD San Diego Regional Office (received on 02/02/2024). According to the LIC624, Licensee on 01/30/2024 first became aware of an allegation of physical abuse of a sexual nature by Staff #1 (S1) against Resident #1 (R1), via a third-party source. [See LIC 811 Confidential Names List for a description of person identifiers used in this report].

During today’s visit, LPA performed a facility tour / welfare check, collected and reviewed pertinent records, and interviewed S1 and other relevant staff. As of the date of LPA’s visit, R1, who was a hospice patient, had since passed away and thus could not be interviewed.

According to R1’s latest LIC602 Physician’s Report (dated 01/10/2024): R1’s primary diagnosis was “high grade glioblastoma multiforme” (i.e., a malignant cancerous brain tumor) which was Stage 4 (i.e., advanced). R1’s doctor wrote that R1 was occasionally confused and while R1 was ambulatory, R1 was not able to safely leave the facility unassisted.


[CONTINUED ON LIC 809-C, 1 of 2]

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: SOLARIS 36
FACILITY NUMBER: 374603815
VISIT DATE: 03/20/2024
NARRATIVE
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[CONTINUED FROM LIC 809]

Records and staff interviews consistently showed: R1 alleged that during one morning in late January 2024, S1 on one (1) occasion touched R1 inappropriately as S1 was assisting them in their bedroom. During the few days leading up to the incident, as well as the date of the incident, R1 was battling a cold with fever. R1 was so weak that they were on continuous bedrest. While staff brought food and drink to R1 and offered to feed them, S1 drank little and ate nothing for at least three straight (3) days. While R1 was normally accustomed to using the restroom by themselves, during their cold, they required staff help with incontinence care.

Per interview of S1: During the incident, R1 was in bed and S1 wanted to check and see if R1 had soiled themselves. S1 asked R1 to turn their body away from them; R1 understood and complied with turning themselves. S1 then briefly felt R1’s bottom with their hand from the outside (without ever removing or lowering R1’s pants), finding that R1 had not yet soiled themselves. S1 then prompted R1 to turn back to center. During the days R1 was sick, there was evidence of increased confusion. For example, on one occasion, S1 observed that R1 had disrobed, then tried to put their pants on their upper body, and their shirt on their lower body.

Upon learning of the incident, Licensee timely conducted an internal investigation, the findings of which did not support the allegation. R1 did not allege, nor did Licensee discover, any indication of physical injury to R1. Per record review and manager interview: Licensee submitted a written report regarding the alleged physical abuse to CCLD and the San Diego County Long Term Care Ombudsman Program (LTCOP), as required. However, Licensee did not report the allegation to the local law enforcement agency, as was required to be done within 24 hours.

During the course of today’s site visit, LPA’s interviews with staff revealed a separate incident also involving R1: On 01/20/2024, R1 eloped from the facility (meaning they left without staff supervision). After 40 minutes of searching, staff located R1 over one mile from the facility. R1 was uninjured. Law enforcement was not notified or involved in the search. R1’s elopement incident was not reported to CCLD, as was required to be done within seven (7) days of incident occurrence. [CONTINUED ON LIC 809-C, 2 of 2]
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: SOLARIS 36
FACILITY NUMBER: 374603815
VISIT DATE: 03/20/2024
NARRATIVE
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[CONTINUED FROM LIC 809-C, 1 of 2]

LPA observed, and staff interviews confirmed: Licensee did not possess a written Absentee Notification Plan (or an equivalent missing resident policy) as part of the written record of care for R1 or any of the five (5) current residents of the facility. Two (2) residents, Resident #2 (R2) and Resident #3 (R3), were formally diagnosed with dementia. However, Licensee’s staff had manually turned off / disabled staff alert devices on its exterior doors.

Three (3) deficiencies were cited per California Code of Regulations, Title 22, and one (1) deficiency was cited per California Health and Safety Code (refer to the attached LIC 809-D pages). Plans of Correction were jointly developed with the Licensee.

An exit interview was conducted with Rivera, to whom a copy of this report, the LIC 809-D pages, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 03/20/2024 06:40 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 03/20/2024 06:39 PM


Created By: Dang Nguyen On 03/20/2024 at 05:08 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: SOLARIS 36
FACILITY NUMBER: 374603815

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/19/2024
Section Cited
CCR
87211(c)

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87211 Reporting Requirements: “(c) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours as required by Welfare and Institutions Code Section 15630(b)(1).”
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CCLD subsequently cross-reported the incident to local law enforcement. Licensee agreed to utilize a third-party source to retrain its staff on Abuse definitions and How to Be a Mandated Reporter in California. Licensee agreed to E-mail LPA the training sign-in sheet by the POC due date.
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This requirement was not met, as evidenced by: Based on records and interviews, for 1 of 6 residents (R1), licensee had knowledge of suspected physical abuse against them which did not result in serious bodily injury, and did not report it to the local law enforcement agency within twenty-four (24) hours. This posed a potential safety and personal rights risk to persons in care.
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Type B
04/19/2024
Section Cited
CCR87211(a)(1)(D)

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87211 Reporting Requirements: "(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency…within seven days of the occurrence of any of the events specified...(D) Any incident which threatens the welfare, safety or health of any resident."
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Licensee agreed to compose an LIC624 Incident Report describing R1’s January 2024 AWOL incident, and to send a copy of the LIC624 to the CCLD San Diego Regional Office (CCLASCPSanDiegoRO@dss.ca.gov). Licensee agreed to utilize a third-party source to retrain its facility managers on Regulation 87211 Reporting Requirements. Licensee agreed to E-mail LPA the training sign-in sheet by the POC due date.
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This requirement was not met, as evidenced by: Based on records and interviews, 1 of 6 residents (R1) had an incident which threatened their welfare, safety, or health, and Licensee did not submit a written report of the incident to the licensing agency within seven days of incident occurrence. This posed a potential health and safety risk to persons 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:Lizzette Tellez
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 03/20/2024 06:41 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 03/20/2024 06:40 PM


Created By: Dang Nguyen On 03/20/2024 at 05:11 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: SOLARIS 36
FACILITY NUMBER: 374603815

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/19/2024
Section Cited
HSC
1569.317

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1569.317 Absentee Notification Plan for Missing Residents: “Every residential care facility for the elderly…shall…develop and comply with an absentee notification plan…The plan shall include…a requirement that an administrator of the facility, or his or her designee, inform the resident’s authorized representative when that resident is missing from the facility…and the circumstances in which [they] shall notify local law enforcement.”
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Licensee agreed to write an Absentee Notification Plan/policy meeting the requirements of CA H&S Code 1569.317, and to train all its staff on it. Licensee also agreed to place a copy of said Absentee Notification Plan in the care file for every current and future client in care, right next to (i.e., as an addendum to) that client’s Needs and Services Plan. Licensee agreed to E-mail the Plan and the training sign-in sheet to LPA, by the POC due date.
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This requirement was not met, as evidenced by: Based on records and interviews, licensee’s staff did not develop an absentee notification plan for 6 of 6 residents (R1 through Resident #6), which posed a potential safety risk to persons in care.
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Type B
04/19/2024
Section Cited
CCR87705(j)

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87705 Care of Persons with Dementia: “(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.” This requirement was not met, as evidenced by:
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During today’s visit: Licensee activated (turned on) the auditory alarms at each exterior door (other than the lobby front door). Licensee agreed to retrain its staff to keep all such alarms activated 24/7. Licensee agreed to E-mail a copy of the staff training sign-in sheet to LPA, by the POC due date.
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Based on records and interviews, during today’s visit, Licensee did not have continuously active auditory devices or other staff alert features to monitor exits, which posed a potential safety risk to 2 of 5 residents (R2 and R3) 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:Lizzette Tellez
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2024


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