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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603838
Report Date: 01/04/2023
Date Signed: 01/04/2023 03:15:26 PM

Unsubstantiated


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
03/22/2021 and conducted by Evaluator Natasha Persaud
COMPLAINT CONTROL NUMBER: 08-AS-20210322113652
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:0CENSUS: DATE:
01/04/2023
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:TIME COMPLETED:
03:05 PM
ALLEGATION(S):
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-Resident sustained multiple falls resulting in hospitalization due to neglect
-Facility staff did not allow resident's medical provider access to the facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Natasha Persaud concluded the complaint investigation regarding the above mentioned allegations. The facility is closed, reports mailed certified.

During the course of the investigation, the facility was toured, records reviewed, and interviews conducted with staff, residents, and outside sources. It was alleged Resident #1 (R1) sustained multiple falls resulting in hospitalization due to neglect. R1’s Physician’s Report dated 07/05/2018 indicated R1 was non-ambulatory and used a wheelchair. R1 has a diagnosis of a Major Neurocognitive Disorder along with Chronic Lower Back Pain. It also indicated R1 required assistance with bathing; dressing/grooming; toileting; and medication management. Facility’s Care Plan indicated R1 was confused and pleasant but needed cueing for safety awareness. Care Plan also stated R1 required assistance with showering, grooming, toileting, and transfers of one person assist with the use of a gait belt. R1 was also documented as a fall risk, with a fall prevention in place, which was a tab alarm. Staff interviews revealed R1 did not have many falls, R1 would get up and slide down to the ground from their bed, not fall. Continued on an LIC 9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2023
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 2
Control Number 08-AS-20210322113652
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: 01/04/2023
NARRATIVE
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Staff interviews confirmed R1 had a tab alarm in place and bed rails, as a safety measure. Staff interviews also revealed if they heard R1’s tab alarm alert go off they would head to R1’s room. Additional staff interviews revealed if they are in the middle of changing a resident’s diaper or showering them, then R1 would have to wait. R1’s medical records reflected multiple visits to the emergency room for different reasons. There was one emergency room visit on 06/17/2020, where R1 did have a fall and sustained an injury. Outside source interviews revealed on 06/17/20, R1 fell out of bed, trying to get up. R1 was transported by ambulance to the emergency room on 06/17/20 and was released on 06/18/20, back to the facility. A review of hospital records indicated R1 was diagnosed with a non-displaced fracture of back and was not a candidate for surgery. R1 was provided with a back brace and prescribed an additional bed rail. R1 had a previous fall on 03/28/20, no injuries were sustained. R1’s authorized representative’s interview confirmed R1 did not have multiple falls resulting in hospitalization. R1’s authorized representative’s interview also revealed R1 has a history of back issues and the fracture sustained was not serious. Therefore, R1 returned to the facility with a back brace. A review of R1’s medical records indicated R1 did not have multiple falls resulting in hospitalization.

It was also alleged, the facility staff did not allow resident's medical provider access to the facility. It was reported staff did not come to the locked gate or answer the facility phone for approximately 45 minutes. R1’s medical provider was unable to gain access to evaluate R1 due to the locked gate. The facility has a gate that requires a code for entry. There’s a sign posted on the gate with the facility phone number and the gate code. Staff interviews revealed they are unable to answer the facility phone if they are in the middle of assisting residents with their activities of daily living. Staff confirmed the facility phone number and gate code are posted on the gate in a plastic protector. On 03/29/21, LPA observed the sign on the gate during the virtual visit, which included both the facility phone number and code. Administrator’s interview revealed all medical providers are provided with the code and the code is posted on the gate. Outside source interviews revealed not having trouble accessing entry to the facility. R1’s authorized representative’s interview revealed being contacted by the medical provider and providing them with the code to gain access.

During the course of the investigation interviews were conducted and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegations. The allegations are deemed unsubstantiated. A copy of these reports were sent certified mail to the licensee.

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2023
LIC9099 (FAS) - (06/04)
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