374603843-11-2-2020-08-AS-RHEK-BVV7UG-20201130205819

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603843
Report Date: 11/02/2020
Date Signed: 11/02/2020 12:35:18 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
09/14/2020 and conducted by Evaluator Natasha Persaud

COMPLAINT CONTROL NUMBER: 08-AS-20200914101614

FACILITY NAME:	HOME AWAY FROM HOME ELDERLY CARE		FACILITY NUMBER:	374603843
ADMINISTRATOR:	NIMER, ROSANA S		FACILITY TYPE:	740
ADDRESS:	11025 AVENIDA DEL GATO		TELEPHONE:	(619) 846-1924
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92126
CAPACITY:	6	CENSUS: 2	DATE:	11/02/2020
		UNANNOUNCED	TIME BEGAN:	11:46 AM
MET WITH:	Licensee, Rosana Nimer		TIME COMPLETED:	12:05 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Unlawful eviction

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Natasha Persaud contacted the facility via video conference, due to COVID-19, to conclude the complaint investigation. LPA identified herself and discussed the purpose of the call with Licensee, Rosana Nimer.

During the investigation, LPA toured the facility, reviewed records, and conducted interviews with staff and outside sources. It was reported Resident #1 (R1) was taken to the hospital for evaluation. Upon evaluation, it was discovered R1 required hospice services. The facility does not have a Hospice Waiver. Licensee’s interview revealed the facility does not allow residents on hospice services. However, the Admission Agreement states hospice services will be provided, which was agreed upon and signed by R1’s responsible party. The licensee admitted she denied resident's return from the hospital with hospice services. Licensee did not allow R1 to return to the facility or provide R1 with a 30 day written eviction. R1 was unlawfully evicted. Continued on an LIC 9099C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: John Rante	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Natasha Persaud	TELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2020

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 3

Control Number 08-AS-20200914101614

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: HOME AWAY FROM HOME ELDERLY CARE	FACILITY NUMBER: 374603843
	VISIT DATE: 11/02/2020

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Based on interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 8, is being cited on the attached LIC 9099D. [See LIC 811 Confidential Names List to identify Resident #1]. An exit interview was conducted with Rosana Nimer, Licensee, via virtual visit, and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided to the Licensee via electronic mail. An electronic read receipt confirmation was requested to be sent by the Licensee upon receipt of the documents.

SUPERVISOR'S NAME: John Rante	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Natasha Persaud	TELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 08-AS-20200914101614

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: HOME AWAY FROM HOME ELDERLY CARE	FACILITY NUMBER: 374603843
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/02/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/16/2020 Section Cited CCR 87224(a)(4)	1 2 3 4 5 6 7	Eviction Procedures- If, after admission, it is determined that the resident has a need not previously identified and a reappraisal has been conducted pursuant to Section 87463, and the licensee and the person who performs the reappraisal believe that the facility is not appropriate for the resident. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee stated she will revise her Admission Agreement, and Plan of operation to omit Hospice Services. In addition, Licensee stated she will ensure all new admissions are made aware the facility will not service hospice residents.
	8 9 10 11 12 13 14	Licensee did not provide R1 with a written 30 day eviction. This poses a health and safety risk to residents 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: John Rante	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Natasha Persaud	TELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2020

LIC9099 (FAS) - (06/04)

Page: 3 of 3