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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603838
Report Date: 06/18/2021
Date Signed: 07/03/2021 10:00:08 PM



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
02/20/2020 and conducted by Evaluator Debbie Correia
COMPLAINT CONTROL NUMBER: 08-AS-20200220141014
FACILITY NAME:ACORN OAKS MANOR IIFACILITY NUMBER:
374603838
ADMINISTRATOR:CHEN, HATTIEFACILITY TYPE:
740
ADDRESS:6217 ACORN STTELEPHONE:
(619) 265-8416
CITY:SAN DIEGOSTATE: CAZIP CODE:
92115
CAPACITY:14CENSUS: 8DATE:
06/18/2021
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Office Manager, Jamilia HallakTIME COMPLETED:
01:40 PM
ALLEGATION(S):
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Staff are not managing resident incontinence.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced visit to deliver investigative findings on the above listed complaint allegation. LPA was met and granted entry into the facility by Office Manager, Jamilia Hallak. LPA identified herself explained the reason for the visit.

The Department’s investigation consisted of staff, resident, and outside source interviews and a tour of the facility. It also consisted of a resident, facility and medical record review.

It was alleged that facility staff are not properly performing resident’s (R1) (See Confidential Names List LIC 811) incontinence care. Interviews with several outside sources and medical notes revealed R1’s briefs were observed to be saturated and have soaked through the bedding when conducting visits to the facility on several occasions. Interview with facility staff, and a facility record review, revealed during the time of R1's stay, there have been issues with several staff not properly caring for residents, and have since been replaced. Interviews with residents revealed no complaints, however the facility has improved since a change in staff. Due to the level of cognitive ability R1 was unable to be interviewed.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021
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 5
Control Number 08-AS-20200220141014
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 II
FACILITY NUMBER: 374603838
VISIT DATE: 06/18/2021
NARRATIVE
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Based on LPA Correia's investigation, the above allegation is determined to be substantiated. A substantiated finding means the allegation is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted with Office Manage Hallak. A copy of this report, the LIC 809D, and Licensee Appeal Rights (9058 01/16) were emailed to Office Manage after the conclusion of the visit, LPA Correia requested an electronic message reply to confirm receipt of these documents.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 08-AS-20200220141014
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 II
FACILITY NUMBER: 374603838
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/18/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/30/2021
Section Cited
CCR
87411
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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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 Office Manager Jamilla Hallak will coordinate with Administrator Heather Myers to provide CCL with training logs that have been conducted by their incontinent care supplier (Total Dry), as well as in-service trainings conducted by facility staff. Documents will be provided to CCL by POC due date.
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Based evidence obtained through interviews, the caregivers during the time of R1's stay at the facility the staff were not meeting the needs of the R1's incontinent care needs. One out of 4 residents in care were lying in soaked briefs to the point of saturating the mattress. This poses a potential health risks to residents 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: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
02/20/2020 and conducted by Evaluator Debbie Correia
COMPLAINT CONTROL NUMBER: 08-AS-20200220141014

FACILITY NAME:ACORN OAKS MANOR IIFACILITY NUMBER:
374603838
ADMINISTRATOR:CHEN, HATTIEFACILITY TYPE:
740
ADDRESS:6217 ACORN STTELEPHONE:
(619) 265-8416
CITY:SAN DIEGOSTATE: CAZIP CODE:
92115
CAPACITY:14CENSUS: 8DATE:
06/18/2021
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Office Manager, Jamilia HallakTIME COMPLETED:
01:40 PM
ALLEGATION(S):
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Resident mattress was deflated.
Staff are not following special diet for the resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced visit to deliver investigative findings on the above listed complaint allegations. LPA was met and granted entry into the facility by Office Manager, Jamila Hallak to whom was explained the reason for the visit.

The Department’s investigation consisted of staff, resident, and outside source interviews and a tour of the facility. It also consisted of a resident record.

It was alleged that resident's (R1) (See Confidential Names List LIC 811) mattress was soaked with urine and had a strong odor of urine. Interviews with facility staff revealed they were not aware of this incident, and have ensured the mattress remains plugged in. Interviews with residents in care revealed no complaints regarding their mattresses. Due to the level of cognitive ability R1 was unable to be interviewed.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 08-AS-20200220141014
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 II
FACILITY NUMBER: 374603838
VISIT DATE: 06/18/2021
NARRATIVE
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It was also alleged that R1 was not being fed a proper diet. Interviews with an outside source revealed R1 requires pureed food and the facility did not have a blender to provide proper meals. Interviews with staff stated pureed meals are provided to R1 and they have a proper blender on facility grounds. During a tour of the facility LPA Correia observed a puree blender in the facility kitchen. Interview with residents revealed no complaints regarding meals, however they did not require a pureed diet. Due to the level of cognitive ability R1 was unable to be interviewed.

Due to lack of corroborating evidence, the findings regarding the above allegations were established to be unsubstantiated. This finding means although the allegation may have happened or could be valid, there is not a preponderance of evidence to prove that the alleged violation occurred.

An exit interview was conducted with Office Manager, Hallak. A copy of this report and Licensee/Appeals Rights (9058 01/16) was emailed to Office Manage, Hallak at the conclusion of the visit, LPA Correia requested an electronic message reply to confirm receipt of these documents.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5