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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604019
Report Date: 06/18/2021
Date Signed: 06/22/2021 08:40:50 AM

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
12/31/2019 and conducted by Evaluator Daniel Pena
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20191231162534
FACILITY NAME:POINT LOMA ELDER CAREFACILITY NUMBER:
374604019
ADMINISTRATOR:GAURAV RATHIFACILITY TYPE:
740
ADDRESS:3941 LIGGET DRIVETELEPHONE:
(619) 255-6448
CITY:SAN DIEGOSTATE: CAZIP CODE:
92106
CAPACITY:6CENSUS: 5DATE:
06/18/2021
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Gaurav Rathi, AdministratorTIME COMPLETED:
04:10 PM
ALLEGATION(S):
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-Staff left resident in soiled clothing
-Staff failed to provide proper care for resident
-Resident’s signal system was not operating
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Daniel Pena visited the facility unannounced to deliver findings for this complaint investigation. LPA identified himself to Gaurav Rathi, Administrator, explained the purpose of the visit and was allowed entry into the facility.

The Department’s investigation of the above-mentioned allegations consisted of a review of facility, resident and outside source records and interviews with residents, facility staff and outside sources.

Records show that Resident 1 (R1) [Licensee provided LIC 811 Confidential Names List to identify resident] resided in the facility from July 2019 until their passing in April 2020. Documentation also reflects that R1 received palliative care from September 2019 to April 2020. Evidence determined, that on separate occasions, medical professionals observed R1 wearing urine soaked and doubled undergarments which had also soiled R1’s disposable bed cover. Records additionally showed that medical professionals observed and documented that R1 had skin breakdown on several portions of their body.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Daniel Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021
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 4
Control Number 08-AS-20191231162534
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: POINT LOMA ELDER CARE
FACILITY NUMBER: 374604019
VISIT DATE: 06/18/2021
NARRATIVE
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-Continued LIC9099-

Additionally, records indicated that on more than one occasion, medical professionals had to provide training and reminders to facility staff on incontinence care and repositioning R1. Staff and outside source interviews revealed that live-in staff do not provide care after their work hours end.

Interviews with the Licensee and outside sources revealed that for several months leading up to December 2019, the facility did not have dedicated night staff providing incontinence care to residents. According to the Licensee, the facility was experiencing staffing issues. Subsequent to CCLD consultation, in December 2019, the facility modified its scheduling to ensure staff were present during the night and provided incontinence care to include repositioning residents every two hours and checking and changing their undergarments. Staff also began logging these activities.

This investigation revealed that according to medical records chair and bed alarms were placed in R1’s room along with other durable medical equipment. The alarms were placed in R1’s room as R1 was considered a high-risk for falls. Interviews with independent outside sources maintained that facility staff did not respond to alarms or check if the alarms were working. On one occasion in December 2019, a visitor observed R1’s bed alarm audibly sounding for several minutes. Facility caregivers did not check on the alarm until the visitor had to alert them. On other occasions, visitors noticed that R1’s alarm was not working at all. Staff interviews affirmed that facility employees do not check bed alarm batteries or if the alarms are working.

Based on interviews and review of records, the above allegations are Substantiated. This finding means that the preponderance of evidence standard has been met and the allegations are valid. Deficiencies have been cited in accordance with California Code of Regulations, Title 22, Division 6, Chapter 8 and noted on the attached LIC 9099-D.

An exit interview was conducted, via virtual visit, and a copy of this report and Licensee/Appeal Rights (LIC 9058 01/16) were provided to Mr. Rathi, via electronic mail. An electronic read receipt confirmation was requested to be sent by the Administrator upon receipt of the documents.
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Daniel Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 08-AS-20191231162534
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: POINT LOMA ELDER CARE
FACILITY NUMBER: 374604019
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/18/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/08/2020
Section Cited
CCR
87625
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87625 Managed Incontinence (b) …the licensee shall be responsible for the following:(3) Ensuring that incontinent residents are kept clean and dry... This requirement was not met as evidenced by LPA
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On January 8, 2020, the Administrator implemented immediate schedule changes with existing staff to ensure at least one employee is on duty through the night shift hours to provide incontinence care for the residents in care. The Administrator also implemented policy requiring staff to record administered incontinence care on activity logs.This deficiency has been addressed.
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interviews and review of documents determined that due to staff shortages on night shift, R1 and other memory care residents were not afforded incontinence care during night shift hours. This posed a potential risk to the health and safety of all residents in care.
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Type B
01/08/2020
Section Cited
CCR
87705
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87705 Care of Persons with Dementia (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs…(A) In addition to requirements
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On January 8, 2020, the Administrator implemented schedule changes with existing staff to ensure at least one employee is on duty through the night shift hours to provide care for R1 and all residents in care. This deficiency has been addressed.
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specified in Section 87415, Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal or observation to require awake night supervision. This requirement was not met as evidenced by LPA interviews and records review; the Licensee admittedly did not ensure proper care was provided to R1 and other residents due to a night shift staff shortage. This posed a potential risk to the health and safety to all residents 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.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 08-AS-20191231162534
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: POINT LOMA ELDER CARE
FACILITY NUMBER: 374604019
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/18/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/18/2021
Section Cited
CCR
87411
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87411 Personnel Requirements–General. 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
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The Administrator will review facility policy and provide in-service training to facility staff regarding the use of bed and chair alarms for residents and provide documentation to CCL by POC date.
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evidenced by LPA’s review of facility records and interviews revealed that staff did not check to see if R1’s chair and bed alarm were operational. This posed a potential health and safety risk to residents 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.
SUPERVISORS NAME: Tony Girolami
LICENSING EVALUATOR NAME: Daniel Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4