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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603837
Report Date: 07/05/2024
Date Signed: 07/05/2024 10:57:06 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
05/13/2021 and conducted by Evaluator Dang Nguyen
COMPLAINT CONTROL NUMBER: 08-AS-20210513124053
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: 0DATE:
07/05/2024
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 employ staff in numbers sufficient to meet resident needs.
-Licensee used cameras which captured audio.
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 employ staff in numbers sufficient to meet resident needs and that Licensee used cameras in common areas of the facility which captured audio (not just video). CCLD’s investigation involved an unannounced facility tour/welfare check, review of the facility’s Admissions Agreement, and interviews of five (5) relevant residents, nine (9) direct care staff, and facility management.

[CONTINUED ON LIC 9099-C, 1 of 2]
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: 07/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2024
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 7
Control Number 08-AS-20210513124053
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: 07/05/2024
NARRATIVE
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[CONTINUED FROM LIC 9099]

Employee work schedules and interviews of managers and direct care staff generally aligned to show: The staff who worked at Acorn Oaks Manor I also worked at Acorn Oaks Manor II (a separate RCFE facility located next-door). The combined morning “AM shift” for both facilities usually consisted of one (1) cook, one (1) medication technician, plus two (2) to three (3) more caregivers, and combined afternoon/evening “PM shift” usually consisted of one (1) medication technician plus two (2) to three (3) more caregivers. The combined overnight/graveyard NOC shift usually consisted of two (2) caregivers, one of whom was also cross trained to pass medications. Interviews of direct care staff, managers, and residents generally aligned to show: When call-outs (i.e. staff not showing up for their scheduled shift) occurred on AM and PM shifts, the open/vacant shifts were usually successfully backfilled by peer staff. The facility also had two (2) managers who worked a few days each week at the facility, and they were known to personally take on medication and caregiving tasks, as needed, to backfill open shifts.

However, multiple residents and multiple direct care staff told CCLD that there were multiple occasions when one of the two scheduled NOC shift direct care staff did not show up for their assigned shift, and their open/vacant shift was not backfilled by a teammate. This left just one (1) direct care staff on duty for both Acorn Oaks Manor I and Acorn Oaks Manor II. The residents and staff interviewed on this topic agreed that having just one caregiver on duty for both facilities on NOC shift was not sufficient to meet residents’ care needs. This also meant that the five (5) residents in care at Acorn Oaks Manor I were temporarily left unsupervised while the lone caregiver went to Acorn Oaks Manor II to care for the fourteen (14) residents living there. Multiple staff interviews, corroborated by a manager’s interview, showed: Even when NOC shift was staffed-to-target, there were some occasions when a NOC shift caregiver observed their shift-mate/teammate briefly asleep on the job, and needing to be woken up to resume their duties. Licensee expected its NOC staff to be awake and actively working for the duration of their shift. Whenever sleeping-on-the-job instances were reported to them, facility management met with the offending employee to address their behavior and/or terminate their employment.


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

DATE: 07/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 08-AS-20210513124053
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: 07/05/2024
NARRATIVE
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[CONTINUED FROM LIC 9099-C, 1 of 2]

Interview of facility manager confirmed that Licensee employed cameras in facility common areas which captured audio of conversations, not just video. Interviews of multiple direct care staff corroborated this. The facility’s Admissions Agreement also referenced use of cameras at the facility which capture audio. CCLD Evaluator Manual’s Reference Material Section 2-5800 titled “Guidelines for Video Surveillance” states: “Under no circumstances may video surveillance in facilities use an audio component.” According to Regulation 87468.2(a)(1), residents of RCFE facilities shall have the right to “a reasonable level of personal privacy in accommodations…visits, communications, telephone conversations…and meetings…”

Based on resident and staff interviews, a preponderance of evidence exists showing that Licensee did not, at all times, employ staff in numbers sufficient to meet resident needs. [The evidence also showed that Licensee also allowed for a temporary absence of staff supervision at the facility, but this particular issue was was already cited via a prior CCLD visit report also associated with this complaint case.] A preponderance of evidence also exists to show that Licensee used cameras which captured audio, violating residents’ right to privacy. For today’s report, two (2) deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D 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 pages, 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: 07/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 08-AS-20210513124053
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: 07/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/05/2024
Section Cited
CCR
87411(a)
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87411 Personnel Requirements – General: “(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.” 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 interviews, Licensee did not ensure that facility personnel were, at all times, sufficient in numbers and competent to provide the services necessary to meet resident needs. This posed a potential health, safety, and personal rights risks to 5 of 5 residents (R1 through R5) in care.
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Type B
07/05/2024
Section Cited
CCR
87468.2(a)(1)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: “(a)…residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (1) To have a reasonable level of personal privacy in… accommodations…visits, communications, telephone conversations…and meetings…”
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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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This requirement was not met, as evidenced by: Based on records and interviews, Licensee did not ensure that 5 of 5 residents (R1 through R5) had a reasonable level of personal privacy in accommodations, visits, communications, telephone conversations, and/or meetings. This posed a potential 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: 07/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 7
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
05/13/2021 and conducted by Evaluator Dang Nguyen
COMPLAINT CONTROL NUMBER: 08-AS-20210513124053

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: 0DATE:
07/05/2024
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’s staff neglected resident, resulting in serious bodily injury.
-Licensee did not ensure incontinence care supplies were available to resident(s).
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Dang Nguyen concluded an investigation regarding the above prior complaint allegation. 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 on 03-09-2021, Licensee’s Staff #1 (S1) ignored/neglected Resident #1 (R1)’s call for help, leading to R1 trying to get out of bed without assistance and thereafter falling, resulting in serious bodily injury. They also alleged that Licensee did not ensure incontinence care supplies were available to residents, because there were multiple occasions when Licensee did not timely restock/replenish them. CCLD’s investigation involved an unannounced facility tour/welfare check and interviews of facility managers, direct care staff, residents, and outside sources. The Department also reviewed pertinent facility care records, ambulance records, and hospital records.

[CONTINUED ON LIC 9099-C, 1 of 2]
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 07/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 08-AS-20210513124053
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: 07/05/2024
NARRATIVE
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[CONTINUED FROM LIC 9099-A]

According to R1’s LIC602 Physician’s Report and corroborated by their LIC602 Pre-Placement Appraisal: R1 was diagnosed with Parkinson’s Disease, had neuropathy and weakness in their upper and lower extremities, and were “non-ambulatory.” The care plan which Licensee authored said R1 was “at risk for fall” because they had “decreased muscular coordination” and “balance problems” when walking and even standing. This care plan, corroborated by interviews of facility staff and outside sources, showed R1 was equipped with a pendant call device (to summon staff), an adjustable hospital bed (which could be positioned lower to the ground), a chair alarm, a bed alarm, a fall mat beside their bed, and a side rail for their bed, and facility staff were to check on R1 “regularly throughout the day, around the clock.”

Per the LIC624 Incident Report (which Licensee self-submitted to CCLD) and interviews of facility managers and direct care staff, staff called 911 after R1 had an unwitnessed fall in their bedroom on 03-09-2021 around 4:30 PM. According to hospital / emergency room (ER) records: CT scans showed R1 had a traumatic “large right-sided subdural hematoma with midline shift and brain compression,” for which R1 soon after underwent “right parietal craniotomy” surgery for “decompression.” The surgery was successful in stabilizing R1’s condition, and R1 later recovered enough to be discharged from hospital care.

Per interview of R1’s responsible person (RP): They confirmed R1 had Parkinson’s Disease and a history of multiple falls at home (prior to moving to the facility). Multiple of these falls involved head contact resulting in blood collecting under R1’s skull in tissues outside/surrounding their brain. RP said that the ER surgeon explained to them that R1’s latest 03-09-2021 fall caused the blood to pool, which increased the pressure placed on R1’s brain. RP confirmed that R1 often tried to get up without asking for help from others.

Per interview of R1 themselves: They confirmed having Parkinson’s disease, experiencing numbness in their hands and feet, having poor balance, and having a history of multiple falls at their home (prior to moving into the facility). R1 said of those earlier falls, “I kept hitting my head.” While R1 did not remember the circumstances leading up their 03-09-2021 fall, they told CCLD their opinion that their latest brain bleed (which ER staff recently identified) could have been caused by their prior falls too. During the interview, R1 was observed to be wearing their pendant call device, and they said, “I know how to use it.”

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

DATE: 07/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 08-AS-20210513124053
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: 07/05/2024
NARRATIVE
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[CONTINUED FROM LIC 9099-C, 1 of 2]

Per interview of S1: S1 knew R1 to be a “big fall risk” even prior to the incident and checked on them regularly. They said R1 required staff help with transferring but often did not ask for said help. For the specific 03-09-2021 fall that is the subject of this complaint, R1 did not ask for help (either verbally or with their pendant call device) before trying to get up out of bed by themselves. S1 was nearby but not inside R1’s bedroom when R1 fell. S1 heard the noise of the impact and quickly responded, finding R1 face down on the floor. S1 called 911 and had R1 remain prone until paramedics arrived. S1 denied ignoring R1 leading up to or after the fall.

Licensee’s staff maintained date and time-stamped progress notes on R1, which showed: On 03/08/2021 (the day before the incident), Staff #2 (S2) wrote at 10:00 AM that R1 had been “trying to get out of bed on [their] own,” and that S2 “had to go to [their] room multiple times to talk to [R1] and let [them] know to ring [their] bell for help.” S2 also wrote that they personally spoke to/briefed teammates about R1 trying to get out of bed on their own. At 7:37 PM that same day, S2 wrote that R1 slid down to the bathroom floor saying they could not feel any movement in their legs. On 03/09/2021 at 1:15 PM (just a few hours before the incident), S2 wrote they verbally asked/reminded R1 to “please not get out of bed on [their] own” and to “ring [their] bell for help to transfer.” However, R1 replied that they did not intend to comply. S2 wrote they advised their trainee that day, caregiver Staff #3 (S3), about R1’s high fall risk.

Based on records and interviews, CCLD did not find a preponderance of evidence to prove that S1, or any other staff, ignored/neglected R1 leading up to their 03/09/2021 fall with injury. Also, there was not a preponderance of evidence showing Licensee did not ensure incontinence care supplies were available to residents. These two (2) allegations were therefore Unsubstantiated, and no deficiencies were cited for them.

A copy of this report 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: 07/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 7