374604019-10-12-2023-08-AS-DPOL-CX5MQN-20231031094902

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604019
Report Date: 10/12/2023
Date Signed: 10/12/2023 10:08:22 AM

Substantiated

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
09/12/2022 and conducted by Evaluator Riza Gloria Alvarez

COMPLAINT CONTROL NUMBER: 08-AS-20220912085344

FACILITY NAME:	POINT LOMA ELDER CARE		FACILITY NUMBER:	374604019
ADMINISTRATOR:	GAURAV RATHI		FACILITY TYPE:	740
ADDRESS:	3941 LIGGET DRIVE		TELEPHONE:	(619) 255-6448
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92106
CAPACITY:	6	CENSUS: 6	DATE:	10/12/2023
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Administrator Gary Rathi		TIME COMPLETED:	10:05 AM

ALLEGATION(S):

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Neglect/Lack of supervision of resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Riza Alvarez conducted an unannounced visit on 10/12/2023 to deliver the findings of a complaint investigation initiated in September 2022. LPA identified herself to Staff Nida Capiendo. Administrator Gary Rathi arrived at the facility shortly.

On 09/12/2022, Community Care Licensing Division (CCLD) received a complaint where it was alleged that Resident 1 (R1) fell and sustained minor injuries due to neglect/lack of supervision by facility staff.
The Department investigated the above complaint allegation. The investigation consisted of interviews with facility staff and outside sources, observations, and records review of documents pertinent to the investigation. A tour of the facility premises was conducted on 09/20/2022.

Facility records showed that R1 used a walker and sometimes used a wheelchair and was assessed as non-ambulatory.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Riza Gloria Alvarez	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

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

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20220912085344

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: POINT LOMA ELDER CARE	FACILITY NUMBER: 374604019
	VISIT DATE: 10/12/2023

NARRATIVE

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On 09/12/2022, R1 was outside at the facility garden sitting in a wheelchair when Staff 1 (S1) asked R1 to come inside because it was raining. When R1 refused, S1 attempted to wheel R1 inside the facility. According to witness statements, the wheelchair wheels locked due to a crack in the concrete garden ramp, causing R1 to fall forward out of their wheelchair onto their knees and sustain minor abrasions.

Based on interview with Staff 2 (S2) who was on duty with S1 on 09/12/2022, it was found that when R1 refused to go inside, S1 pushed R1’s wheelchair then let go of the wheelchair. Interviews with an external source confirmed that as a result, R1 fell forward and received minor abrasions on both knees. It was also found that S1 omitted pertinent facts in reporting the incident to the licensee, as evidenced by the incident report submitted to CCLD on 09/19/2022. Administrator stated that as soon as S2 reported the matter to the Administrator, immediate action was taken with respect to S1's actions.

Based on interviews, observations, and records review, sufficient evidence was obtained to support the allegation. The preponderance of evidence standard has been met. Therefore, the allegation was determined to be SUBSTANTIATED. A plan of correction was jointly developed with the Administrator and was reflected in the LIC9099-D page.

The report was discussed, and an exit interview was conducted with Administrator Rathi. A copy of this report, the LIC9099-D page, Confidential Names (LIC811), and Licensee/Appeal Rights (LIC9058 03/22) were provided to Mr. Rathi at the conclusion of the visit. The signature below serves as confirmation that the documents were received.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Riza Gloria Alvarez	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 08-AS-20220912085344

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: POINT LOMA ELDER CARE	FACILITY NUMBER: 374604019
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/12/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/13/2023 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Re-train staff on provision of care and supervision of persons in care. Licensee will submit to CCLD the in-service training record and roster of participants of the training.
	8 9 10 11 12 13 14	Based on interviews and records review, facility staff (S1) did not provide required assistance to 1 out of 6 residents (R1).This posed a potential safety risk to a person 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: Lizzette Tellez	TELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Sabel Martinez	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023

LIC9099 (FAS) - (06/04)

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