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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603838
Report Date: 07/05/2024
Date Signed: 07/05/2024 02:11:00 PM

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
05/10/2021 and conducted by Evaluator Dang Nguyen
COMPLAINT CONTROL NUMBER: 08-AS-20210510134517
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: 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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-Absence of staff supervision.
-Licensee did not employ staff in numbers sufficient to meet resident needs.
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 Licensee did not employ staff in numbers sufficient to meet resident needs, and that there were occasions of absence of staff supervision at the facility. CCLD’s investigation involved an unannounced facility tour/welfare check, review of pertinent records, and interviews of five (5) relevant residents, nine (9) direct care staff, and facility management.

Employee work schedules and interviews of managers and direct care staff generally aligned to show: The staff who worked at Acorn Oaks Manor II also worked at Acorn Oaks Manor I (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,... [CONTINUED ON LIC 9099-C]
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-20210510134517
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: 07/05/2024
NARRATIVE
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[CONTINUED FROM LIC 9099] ...and the 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 fourteen (14) residents in care at Acorn Oaks Manor II were temporarily left unsupervised while the lone staff went to Acorn Oaks Manor I to care for the five (5) 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.

Based on resident and staff interviews, a preponderance of evidence exists showing that at times, Licensee did not employ staff in numbers sufficient to meet resident needs, and at times, Licensee allowed for an absence of staff supervision at the facility. Two (2) deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D page). For the latter violation, 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: 07/05/2024
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-20210510134517
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: 07/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/05/2024
Section Cited
CCR
87464(f)(1)
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87464 Basic Services: “(f) Basic services shall at minimum include: (1) Care and supervision…” 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 staff supervision was provided, at all times, to 14 of 14 residents (R1 through R14). This posed an immediate health, safety, and personal rights risks to persons in care.
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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 14 of 14 residents (R1 through R14) 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: 3 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
05/10/2021 and conducted by Evaluator Dang Nguyen
COMPLAINT CONTROL NUMBER: 08-AS-20210510134517

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: 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 misused medication to restrain a resident.
-Licensee’s staff tried to financially abuse a resident.
-Licensee unlawfully evicted a resident.
-Licensee tried to undermine an ongoing CCLD investigation.
-Licensee falsified training records.
-Licensee allowed staff to pass medications without required training.
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 the afternoon of 05/04/2021, Licensee’s Staff #1 (S1) misused prescription as-needed (PRN) morphine medication to impair/restrain Resident #1 (rather than the approved reason of mitigating pain per the doctor’s prescription), that S1 tried unsuccessfully to seize cash from and access R1’s bank account, and that Licensee then unlawfully evicted R1 by sending them to a hospital via ambulance. They also alleged that Licensee tried to undermine an ongoing separate CCLD investigation, that Licensee falsified training records, and that Licensee allowed staff to pass medications to residents without the required training.

[CONTINUED ON LIC 9099-C, 1 of 3]
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: 4 of 7
Control Number 08-AS-20210510134517
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: 07/05/2024
NARRATIVE
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[CONTINUED FROM LIC 9099-A]

CCLD’s investigation involved an unannounced facility tour/welfare check and interviews of five (5) relevant residents, nine (9) direct care staff, and facility management. The Department also reviewed pertinent facility care records, hospice agency records, ambulance records, and hospital records for R1. The Department was unable to interview R1 or their agent, having exhausted all attempts to contact both persons.

According to their LIC602 Physician’s Report, while R1 was diagnosed with Amyotrophic Lateral Sclerosis (ALS), they had no dementia or other cognitive impairment, they were not confused/disoriented, they were able to both follow instructions and to communicate. Their LIC603 Pre-Placement Appraisal reiterated that R1 had “no signs of mental deficit,” and that they had good vision and hearing. Per records from R1’s hospice agency showed: Since R1 moved into the facility five (5) days earlier, R1 repeatedly experienced ALS-related body pains, for which they repeatedly requested their as-needed pain medication from facility staff.

According to interview of S1: They denied using morphine (or any other medication) with the intent of impairing/restraining R1. S1 denied trying to seize cash from R1 and denied trying to access R1’s bank account. Even after interviewing other staff and residents, CCLD did not find witnesses to corroborate that S1 attempted these alleged actions against R1. S1 said they arranged for take R1 to go to the hospital on 05/04/2021 due to swelling in their body.

According to transport records, ambulance personnel arrived at the facility at 5:12 PM on 05/04/2021 to pick up R1. They wrote R1’s “chief complaint” was ALS-related “body aches” lasting “several days” and “progressively getting worse.” Per hospital records: R1 arrived at a hospital emergency room (ER) around 6:00 PM, complaining of “pain all over.” R1 had received morphine an hour earlier and it was “not working.” An ER registered nurse (RN) wrote at 7:52 PM that R1 was “alert & oriented X 3.” The RN documented details of their conversations with R1, who coherently verbalized that they did not want to live in a communal setting, but rather wished to return their personal residence with in-home caregivers when it came time to discharge from the hospital.

[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: 5 of 7
Control Number 08-AS-20210510134517
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: 07/05/2024
NARRATIVE
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[CONTINUED FROM LIC 9099-C, 1 of 2]

A social worker from R1’s hospice agency also visited R1 while they were a patient at the hospital. There was no evidence, in either hospital or hospice records, of R1 ever saying that they were wrongly medicated or impaired/restrained with medications by facility staff. There was also no evidence of R1 ever saying that facility staff tried to seize cash from them or tried to access their bank account. However, there was repeated evidence that R1 voluntarily chose not to return to Acorn Oaks Manor II. In their own testimonies, all nine direct care staff interviewed said they knew of zero instances of staff trying to restrain or overmedicate any resident, and zero instances of staff trying to financially abuse any resident. Interviews of four of four other residents corroborated the same.

Interviews of facility managers and direct care staff unanimously showed: Licensee did not try to coach/influence what their staff told CCLD. Licensee did not try to undermine or interfere with the any of the Department’s ongoing investigations. Licensee did not create any false training records or instruct direct care staff to backdate their signatures on such records. Licensee consistently required direct care staff to undergo eight (8) hours of classroom training on medications, followed by at least forty (40) hours of on-the-job training on medications, before allowing said staff to independently pass medications to residents in care.

Based on records and interviews, a preponderance of evidence does not exist to show that Licensee’s staff misused medication to restrain R1 or tried to financially abuse R1. The preponderance of evidence also does not support that Licensee unlawfully evicted R1, undermined an ongoing CCLD investigation, falsified training records, or allowed staff to pass medications to residents without required training. These six (6) 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: 6 of 7