374603838-1-5-2024-08-AS-IESA-CZZTVM-20240131140407

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603838
Report Date: 01/05/2024
Date Signed: 01/05/2024 10:03:32 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
12/21/2020 and conducted by Evaluator Iby Strong

PUBLIC

COMPLAINT CONTROL NUMBER: 08-AS-20201221162628

FACILITY NAME:	ACORN OAKS MANOR II		FACILITY NUMBER:	374603838
ADMINISTRATOR:	CHEN, HATTIE		FACILITY TYPE:	740
ADDRESS:	6217 ACORN ST		TELEPHONE:	(619) 265-8416
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92115
CAPACITY:	0	CENSUS: 0	DATE:	01/05/2024
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Report Mailed to Licensee via USPS Certified Mail		TIME COMPLETED:	08:01 AM

ALLEGATION(S):

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Neglect/Lack of Supervision resulted in serious injury.
Insufficient staff to meet residents needs.
Licensee did not follow medication destruction requirements.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Iby Strong sent this report to former licensee's last known mailing address via USPS certified mail.

On December 21, 2020, Community Care Licensing (CCL) received a complaint alleging Resident 1 (R1) sustained a serious injury due to neglect/lack of supervision, licensee had insufficient staff to meet resident needs and licensee did not follow medication destruction requirements.

During the investigation, the Department conducted interviews, and reviewed facility records. According to the allegations, on or about October 2020, R1 had an unwitnessed fall that resulted in an undescribed serious injury, such injury was said to have left blood throughout R1’s bedroom. According to Physician Report dated March 26, 2019, R1 was diagnosed with a prior stroke, cancer, and mild cognitive impairment. R1’s Care Plan, dated 12/19/2019, states R1 requires some assistance with transfers, is non-ambulatory and has a history of irritability/impatience. Continue on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Iby Strong	TELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:	DATE: 01/05/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024

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 5

Control Number 08-AS-20201221162628

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ACORN OAKS MANOR II	FACILITY NUMBER: 374603838
	VISIT DATE: 01/05/2024

NARRATIVE

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Continued from LIC9099

Records collected also revealed R1 has had previous falls. Records stated that R1 had been counseled about requesting assistance prior to attempting transfer but R1 was non-compliant. Interview with Administrator confirmed that R1 did have an unwitnessed fall on or about October 2020, and received medical care from an outside hospice agency within the same day. Interview with R1 revealed no corroborating information to the allegation of injury resulted due to neglect of R1. Interview with an outside source did not reveal any information to corroborate the allegation of neglect/lack of supervision.

It was also alleged that the facility had insufficient staff to meet residents’ needs. Interview with Administrator revealed that there were a minimum of three staff members per fourteen residents at any given time. Interview also revealed that staff responded to residents within two minutes of pressing the call light. Interviews with staff did not reveal any information to prove there were not substantial staff to meet resident’s needs. Interview with outside source revealed that enough staff was present to assist residents. There were no records available to corroborate the fact that the facility was not sufficiently staffed.

Lastly, it was alleged that the licensee was not destroying unused medication as required but rather taking them for personal use. Interview with Administrator revealed that facility destroys medication according to regulation and with multiple staff present as witnesses. Interview with staff did not reveal any corroborating information that medication was not being destroyed or was being used by licensee. There were no records available to corroborate allegation about medication destruction.

Based on the Departments interviews, and record reviews there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegations are unsubstantiated. A copy of this report and Appeal and Licensee Rights (LIC 9058 03/22) were provided to the former Licensee, via USPS Certified Mail.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Iby Strong	TELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:	DATE: 01/05/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
12/21/2020 and conducted by Evaluator Iby Strong

PUBLIC

COMPLAINT CONTROL NUMBER: 08-AS-20201221162628

FACILITY NAME:	ACORN OAKS MANOR II		FACILITY NUMBER:	374603838
ADMINISTRATOR:	CHEN, HATTIE		FACILITY TYPE:	740
ADDRESS:	6217 ACORN ST		TELEPHONE:	(619) 265-8416
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92115
CAPACITY:	0	CENSUS: 0	DATE:	01/05/2024
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Report Mailed to Licensee via USPS Certified Mail		TIME COMPLETED:	08:01 AM

ALLEGATION(S):

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Uncleared staff was working at the facility

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Iby Strong sent this report to former licensee's last known mailing address via USPS certified mail.

On December 21, 2020, Community Care Licensing (CCL) received a complaint alleging Staff 1 (S1) was working at the facility for an extended period of time without a background clearance. During the investigation, the Department conducted interviews, and reviewed facility records. According to interview with S1, S1 confirmed that they had been working at the facility without an approved background exemption. Interview with Administrator revealed that they were aware of S1 not having a current background exemption clearance. Records reviewed revealed that S1 was denied a background exemption on December 18, 2019. Interview with Administrator also revealed that S1 was terminated from facility on or about December of 2020 for unrelated reasons.

Continue on LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Iby Strong	TELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:	DATE: 01/05/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 08-AS-20201221162628

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ACORN OAKS MANOR II	FACILITY NUMBER: 374603838
	VISIT DATE: 01/05/2024

NARRATIVE

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Continued from LIC9099-A

Based on the Departments review of facility records and interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiencies are cited per California Code of Regulations, Title 22, Division 6 on the attached 9099D. A copy of this report and Appeal and Licensee Rights (LIC 9058 03/22) were provided to the former Licensee, via USPS Certified Mail.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Iby Strong	TELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:	DATE: 01/05/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 08-AS-20201221162628

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ACORN OAKS MANOR II	FACILITY NUMBER: 374603838
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/05/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/05/2024 Section Cited CCR 87355(e)(1)	1 2 3 4 5 6 7	Criminal Record Clearance(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working... (1)Obtain a California clearance or a criminal record exemption.	1 2 3 4 5 6 7	Immediate health and safety risk was removed as facility closed as of June 15, 2022. Plan of correction cleared.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by:Based on interviews and records reviews the licensee did not have staff background cleared in 1 of 4 staff which posed an immediate Health and Safety risk in 14 of 14 persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Jacob	TELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Iby Strong	TELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:	DATE: 01/05/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 5