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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603837
Report Date: 07/03/2024
Date Signed: 07/08/2024 10:25:02 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
01/06/2021 and conducted by Evaluator Dang Nguyen
COMPLAINT CONTROL NUMBER: 08-AS-20210106101120
FACILITY NAME:ACORN OAKS MANOR IFACILITY NUMBER:
374603837
ADMINISTRATOR:CHEN, HATTIEFACILITY TYPE:
740
ADDRESS:6207 ACORN STTELEPHONE:
(619) 265-8416
CITY:SAN DIEGOSTATE: CAZIP CODE:
92115
CAPACITY:0CENSUS: DATE:
07/03/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:N/A. Report Certified Mailed to Licensee.TIME COMPLETED:
05:00 PM
ALLEGATION(S):
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-Licensee did not timely refill medication, resulting in a resident not receiving medication as prescribed.
-Licensee did not provide timely incontinence care, contributing to resident infection.
-Licensee did not maintain the facility's roof in good repair.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Dang Nguyen concluded an investigation regarding the above prior complaint allegations. Since the facility ceased operations on 06/15/2022 due to Change in Ownership, the allegation findings were delivered to the Licensee via USPS certified mail.

The Complainant alleged that Licensee did not timely obtain/refill Resident #1 (R1’s) medication, resulting in R1 not receiving their medication as prescribed. They alleged that Licensee did not provide timely incontinence care to R1, contributing to infection. They also alleged that Licensee did not maintain the facility’s roof in good repair. CCLD’s investigation involved an unannounced facility tour/welfare check and interviews of facility managers, frontline staff, residents, and outside sources. The Department also reviewed pertinent care and hospital records and photographs received from third-party sources. LPA did not interview R1 because they had moved-out of the facility by the time the complaint was filed and due to their prior-documented memory loss. [CONTINUED ON LIC 9099-C, 1 of 3]
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
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 6
Control Number 08-AS-20210106101120
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: ACORN OAKS MANOR I
FACILITY NUMBER: 374603837
VISIT DATE: 07/03/2024
NARRATIVE
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[CONTINUED FROM LIC 9099]

R1’s LIC602 Physician’s Report and LIC603 Resident Appraisal together showed they had Vascular Dementia (among other diagnoses), were incontinent, were forgetful/confused but also calm/cooperative, and required staff assistance with both changing their Depends and taking their medications. Interviews of staff and outside sources unanimously corroborated these points.

In the facility’s Program Description / Plan of Operation (required to be on file with CCLD), Licensee wrote, “Medication refills will be obtained in a timely manner to ensure residents have all physician ordered medication available,” and that staff are to contact “the dispensing pharmacy to obtain a refill at least seven (7) days prior to running out of a medication…” Licensee also wrote that its staff would provide residents with “scheduled toileting at regular intervals,” and that those residents who wore “incontinent briefs will be changed a minimum of every two hours, including during the night.”

According to the Complainant, around May 2020, there was period (of unknown length) when R1 missed their Depakote medication, due to facility staff running out of it. Then around December 2020, there was a period (of unknown length) when R1 missed both their Depakote and Vimpat medications, again due to facility staff running out. R1’s facility medication list confirmed they were prescribed both Depakote and Vimpat as routine anticonvulsant (anti-seizure) medications, each to be taken twice per day.

In their respective interviews: The Licensee/Administrator Staff #1 (S1) admitted there was an occasion when R1 went two (2) days without one of their seizure medications, due to the facility running out of refills. Facility Manager Staff #2 (S2) admitted there was an occasion when R1 went one (1) day without on of their prescribed medications, due to the facility running out of refills. Facility Supervisor / Med Tech Staff #3 (S3) corroborated that there was at least one occasion when R1 missed medication due to facility staff running out of refills. Facility Med Tech / Caregiver Staff #4 (S4) also said there was at least one occasion when R1 had gone “a couple of days” without their anti-seizure medication due to staff not having the refills.


[CONTINUED ON LIC 9099-C, 2 of 3]
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 08-AS-20210106101120
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: ACORN OAKS MANOR I
FACILITY NUMBER: 374603837
VISIT DATE: 07/03/2024
NARRATIVE
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[CONTINUED FROM LIC 9099-C, 1 of 3]

There was no evidence suggesting R1 experienced any adverse health consequence because of missing their anti-seizure medications while living at the facility. LPA also obtained copies of electronic correspondence from December 2020, in which facility management admitted that R1 had run out of medication, and that the responsible staff were “disciplined and retrained” as a result. In their own interview, Resident #2 (R2), who was fully alert and oriented with intact memory, told LPA that there was also one (1) occasion when they themselves went without their prescribed Insulin medication for “four to five days,” due to the facility staff not timely securing the refill for that medication. R2 denied experiencing any adverse health consequences from that incident.

According to the Complainant, while living at the facility, R1 was twice hospitalized due to Urinary Tract Infection (UTI); the first was in August 2020, and the second was in October 2020. R1 attributed these UTIs to Licensee’s staff not timely changing R1’s depends. Review of hospital records confirmed: On 08-23-2020, facility staff sent R1 to the hospital emergency room (ER) after they became unresponsive. R1 was subsequently hospitalized through 08-26-2020 for “severe sepsis with acute organ dysfunction” caused by “acute UTI (urinary tract infection).” R1 received antibiotics, which successfully resolved R1’s UTI and symptoms. Less than two months later, on 10-08-2020, facility staff again sent R1 to the ER, this time for lethargy and altered mental status. R1 was subsequently diagnosed with “acute UTI” with signs and symptoms of “acute toxic encephalopathy.” R1 again received antibiotics, which successfully resolved R1’s UTI and symptoms.

According to the federal National Institutes of Health (NIH): Good personal hygiene (e.g., timely changing of soiled Depends and cleaning with wet wipes) is a primary preventative factor for UTIs in the elderly. Most facility direct care staff interviewed said their team was usually consistent with changing residents' briefs every few hours. However, several also told CCLD that there were multiple occasions when one of the two scheduled overnight (NOC) direct care staff did not show up for their assigned work shift, and the open/vacant shift was not backfilled. This left just one (1) direct care staff on duty on those nights, which they said was not sufficient staffing to meet residents’ care needs.

[CONTINUED ON LIC 9099-C, 3 of 3]
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 08-AS-20210106101120
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: ACORN OAKS MANOR I
FACILITY NUMBER: 374603837
VISIT DATE: 07/03/2024
NARRATIVE
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[CONTINUED FROM LIC 9099-C, 2 of 3]

R2 told CCLD that facility caregivers typically waited four (4) to six (6) hours before checking on their and their housemates’ Depends to see if they were wet/soiled. R2 said this was “too long.” Resident #3 (R3), who was also alert and oriented with good memory, told CCLD that there were multiple occasions when only one staff person was on duty at night, and they often had to sit in their soiled Depends for too long while waiting for help.

Interviews of the Complainant, facility managers, and facility staff aligned to show: Near the end of 2020, Licensee hired a contractor to install solar panels on top of the facility’s roof, while residents were still living inside. During installation, sections of the existing roof were also removed to be repaired and/or replaced. The roof holes which this project created were temporarily covered with tarp, pending completion. Licensee/Administrator S1 admitted there was an occasion in late December 2020 when it was raining and windy. The tarp(s) blew off the roof, allowing rainwater to enter the facility’s living room and some bedrooms, and necessitating the relocation of two (2) residents from their bedrooms during the nighttime. This event was corroborated by Facility Manager S2 and Med Tech/Caregiver S4. Direct care Staff #5 (S5) and Staff #6 (S6) also recalled water entering the facility during the project and needing to mop the floor with towels and/or blankets. From third-parties, CCLD also obtained a photograph showing significant holes created in the facility's roof, prior to the solar panels being put in.

Based on records reviewed and interviews, the preponderance of evidence shows: There were occasions when Licensee did not timely refill medication, resulting in R1 and R2 not receiving medication as prescribed. Licensee did not consistently and timely meet R1, R2, and R3's incontinence care needs, contributing to R1 developing UTIs for which they need to go to the hospital. During an elective project, Licensee created holes in the roof which allowed rainwater to enter inside, while residents were still inside. Three (3) deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D pages). Since one of these violations resulted in acute resident illness, an Immediate Civil Penalty of $500.00 was assessed/charged (refer to the LIC421-IM page). Since the facility has closed and ceased operations, no Plans of Correction were formed with the Licensee.

A copy of this report, the LIC 9099-D page, the LIC421-IM, and the Licensee/Appeal Rights (LIC9058 03/22) were mailed to the Licensee’s last known address via USPS certified mail.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 08-AS-20210106101120
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: ACORN OAKS MANOR I
FACILITY NUMBER: 374603837
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/03/2024
Section Cited
CCR
87625(b)(2)
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87625 Managed Incontinence: “(b)…the licensee shall be responsible for the following: (2) Ensuring that incontinent residents are checked during those periods of time when time when they are known to be incontinent, including during the night.” This requirement was not met, as evidenced by:
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Since the facility has closed and ceased operations, no Plan of Correction was formed with the Licensee.
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Based on records and interviews, Licensee did not ensure that 3 of 5 residents (R1, R2, and R3) were timely checked during those periods of time when they were known to be incontinent, including during the night. This posed an immediate health and personal rights risk to persons in care.
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Type B
07/03/2024
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care: “(a)(4) The licensee shall assist residents with self-administered medications as needed.” This requirement was not met, as evidenced by:
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Since the facility has closed and ceased operations, no Plan of Correction was formed with the Licensee.
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Based on records and interviews, Licensee did not assist 2 of 5 residents (R1 and R2) with self-administered medications as needed/prescribed, which posed a potential health 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 TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 08-AS-20210106101120
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: ACORN OAKS MANOR I
FACILITY NUMBER: 374603837
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/03/2024
Section Cited
CCR
87307(d)(2)
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87307 Personal Accommodations and Services: “(d) The following space and safety provisions shall apply to all facilities: (2) The premises shall be maintained in a state of good repair and provide a safe and healthful environment.” This requirement was not met, as evidenced by:
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Since the facility has closed and ceased operations, no Plan of Correction was formed with the Licensee.
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Based on photographs and interviews, Licensee did not continuously maintain the facility premises in a state of good repair, affecting 2 of 5 residents (R1 and R4). This posed a potential health, safety, and personal rights 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 TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6