374603913-11-12-2020-08-AS-SJAB-BVUUTR-20201130145219

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603913
Report Date: 11/12/2020
Date Signed: 11/12/2020 11:18:49 AM

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
11/14/2019 and conducted by Evaluator Lizzette Tellez

COMPLAINT CONTROL NUMBER: 08-AS-20191114164624

FACILITY NAME:	NOBLE LIVING II LLC		FACILITY NUMBER:	374603913
ADMINISTRATOR:	LEON, REBECCA		FACILITY TYPE:	740
ADDRESS:	505 HILLS LANE DR		TELEPHONE:	(619) 938-4984
CITY:	EL CAJON	STATE: CA	ZIP CODE:	92020
CAPACITY:	6	CENSUS: 6	DATE:	11/12/2020
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Administrator Debra Bunnell		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Licensee failed to properly administer medication to resident in care, resulting in injury
Facility staff was verbally abusive to residents in care

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Lizzette Tellez contacted the facility via telephone to deliver findings for a complaint investigation due to COVID-19. LPA identified herself and discussed the purpose of the call with Administrator Debra Bunnell.

It was alleged that the licensee failed to properly administer medication to Resident #1 (R1) resulting in injury to R1. Ms. Bunnell was provided with Confidential Names Form in order to identify R1. Investigation consisted of interviews with staff, outside sources, and residents, review of records, and a tour of the facility. Investigation revealed that on the morning of November 7, 2019, R1 suffered an unwitnessed fall and was sent to a hospital via ambulance. Record review, including medical records, revealed that R1 suffered a fall at or around 6:00 AM, while making their way into the bathroom and turning in to the toilet. The fall resulted in minor injuries to R1. R1 denied loss of consciousness and was observed to be fully alert and oriented. Review of resident records and investigative interviews revealed R1 did not require assistance with toileting. Review of facility records and medication logs revealed that R1 was assisted with a medication, which can cause dizziness

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: John Rante	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Lizzette Tellez	TELEPHONE: (619) 219-9755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/12/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2020

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 2

Control Number 08-AS-20191114164624

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: NOBLE LIVING II LLC	FACILITY NUMBER: 374603913
	VISIT DATE: 11/12/2020

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

and loss of coordination as side effects, on November 6, 2019, at 8 PM, and was noted to be effective at 10 PM. R1 was not assisted with medication on the morning of the unwitnessed fall on November 7, 2019, as they were sent out via ambulance prior to the medication pass. This was consistent with medication logs. Review of medication records revealed that all of the centrally stored medications for R1 were prescribed medications with a physician’s order on file. Staff denied providing medication not as prescribed. Medication administration records included logs of administration of medication as needed. The Department was unable to interview R1. Based on a review of records, including medical records, interviews with staff and outside sources, there is insufficient evidence to prove that the licensee failed to properly administer medication to R1 resulting in injury.

It was alleged that Staff #1 (S1) was verbally abusive to residents in care. Ms. Bunnell was provided with Confidential Names Form in order to identify S1. Investigation consisted of interviews with staff, outside sources, and residents, review of records, and a tour of the facility. Interviews with staff, residents, and outside sources did not support or corroborate the allegation. Interviews with residents revealed residents feel safe and comfortable at the facility. Resident #2 (R2), who was alleged to have been verbally abused by S1, denied being verbally abused by S1 or any other staff. Interview with R2 revealed that R2 is content at the facility and does not feel unsafe or disrespected. R2 denied having any negative encounters with S1, and stated that S1 is nice and they have not had any negative encounters. S1 denied having been rude or disrespectful to any residents. Other residents and staff interviewed denied having observed any instances of abuse of any form or negative interactions from other staff, to include S1. Based on interviews with staff, residents, and outside sources, there is insufficient evidence to prove that S1 was verbally abuse to residents in care.

The Department has investigated the above-mentioned allegations and has found that there is insufficient evidence to prove or corroborate the allegations. Therefore, these allegations are deemed unsubstantiated.

An exit interview was conducted with Ms. Bunnell via telephone and a copy of this report along with Licensee/Appeal Rights (LIC 9058 01/16) was provided to her via email. An electronic email read receipt confirms the documents were received.

SUPERVISOR'S NAME: John Rante	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Lizzette Tellez	TELEPHONE: (619) 219-9755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/12/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 2