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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604051
Report Date: 03/13/2024
Date Signed: 03/18/2024 12:57:27 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
04/26/2021 and conducted by Evaluator Debbie Correia
COMPLAINT CONTROL NUMBER: 08-AS-20210426094317
FACILITY NAME:ATRIA RANCHO PENASQUITOSFACILITY NUMBER:
374604051
ADMINISTRATOR:HERNANDEZ, MARIANO QUINNFACILITY TYPE:
740
ADDRESS:12979 RANCHO PENSAQUITOS BLVDTELEPHONE:
(858) 201-6458
CITY:SAN DIEGOSTATE: CAZIP CODE:
92129
CAPACITY:0CENSUS: 56DATE:
03/13/2024
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Closed Facility - Report sent via USPS Certified MailTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Resident received unexplained injuries while in care.
Facility staff did not seek medical attention for a resident.
Facility staff neglected a resident who experienced weight loss.
Facility staff did not meet reporting requirements.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Debbie Correia sent this report to the Licensee's last known mailing address, via USPS certified mail, to deliver the investigation findings for the above-listed allegations. The facility was closed on January 20, 2023.

The Department’s investigation consisted of staff and outside source interviews as well as resident, facility, and outside source records reviews.

It was alleged staff neglect resulted in Resident 1 (R1) sustaining unexplained injuries and extreme weight loss while in care at the facility. It was also alleged staff neglected to seek medical attention for residents in care. A facility records review revealed R1 was admitted to the facility for respite care from April 11, 2021, to April 24, 2021. A facility records review and an interview with Outside Source 1 (OS1) revealed R1’s regular care provider was unavailable during the two weeks in April therefore OS1 had R1 admitted to the facility for short term ‘respite’ care. A facility and resident records review dated April 1, 2021, revealed R1 had a primary diagnosis of Dementia, and displayed behaviors of confusion, sundowning, wandering, and required medication management and general supervision due to their diagnosis. Records also revealed R1 could perform all other Activities of Daily Living Skills (ADLs) and was in overall good physical health at the time of admission. R1 was ambulatory, did not require assistance with showers, toileting, or assistance with ambulating.

This is an amended version of the original report dated 03/13/2024.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024
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 5
Control Number 08-AS-20210426094317
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: ATRIA RANCHO PENASQUITOS
FACILITY NUMBER: 374604051
VISIT DATE: 03/13/2024
NARRATIVE
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A facility records review also revealed on April 23, 2021, R1 had episodes of behaviors the prior two nights and facility staff notified OS1 who subsequently picked R1 up on the following day, April 24, 2021. An interview with OS1 revealed when they picked R1 up from the facility, they were dressed in a jacket and their socks were pulled up high, and upon leaving the facility OS1 noticed blood on R1’s arm and once able to, OS1 conducted a full body check. OS1 found R1’s left hand was bruised, blood on both arms, a deep cut on R1’s right elbow, and a cut on their shin and left leg below the knee. OS1 also noticed R1 had lost a substantial amount of weight in the two week stay at the facility. An outside source records review dated April 28, 2021, revealed R1 lost 15 pounds while at the facility, and had abrasions with overlying eschar on the right elbow and left lower leg, and bruising dorsum of the left hand and arm.

The interview with OS1 also revealed they emailed the facilities Executive Director (ED) to inquire about R1’s injuries but they never responded. OS1 then contacted the facility’s Regional Vice President (VP) who stated they would investigate the matter at hand and when the VP returned OS1’s call they stated that no staff knew how R1 sustained injuries. OS1 sent the VP pictures they had taken of R1’s injury and the VP response to the pictures was that OS1 had no evidence of when the pictures were taken. An interview conducted with ED revealed R1 was observed to be very independent, as they were ambulatory, active and in good shape, however facility records revealed R1 was assessed as a fall risk and would require staff assistance three times a day. The ED also revealed no knowledge or documentation of R1 sustaining any falls or injuries. Pictures of R1’s injuries were presented to the ED who agreed the injuries were more than likely sustained at the facility because the wounds looked old.


This is an amended version of the original report dated 03/13/2024.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 08-AS-20210426094317
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: ATRIA RANCHO PENASQUITOS
FACILITY NUMBER: 374604051
VISIT DATE: 03/13/2024
NARRATIVE
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An interview conducted with Staff 1 (S1) revealed seeing R1’s wound on their elbow but was not aware of any falls. When S1 was asked why they didn’t ask R1 what happened or report the injury S1 couldn’t provide an answer. At the time of S1’s interview they revealed that they had just been fired due to not being able to work their shifts from sustaining an injury themselves. S1 also revealed the facility is understaffed and they had worked shifts alone for two months. During morning shifts there are usually only two caregivers to oversee 31 residents, and staff would sleep while working the night shifts. In addition, S1 revealed residents sustained many falls, and there were residents observed with large bruises and management would not do anything about it. S1 also revealed not saying anything about these issues before because they feared losing their job. S1 then sent Community Care Licensing (CCL) 24 pictures, including but not limited to; injuries of unknown residents, residents in soiled diapers, and soiled clothing, however none of them were pictures of R1. [For Confidential names see LIC 812 List of Confidential Names]

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



Due to the facility’s closure, no exit interview was conducted. A copy of this report, along with Licensee Rights (LIC 9058 01/16), were mailed via USPS certified mail to the last mailing address on file.


This is an amended version of the original report dated 03/13/2024.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 08-AS-20210426094317
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: ATRIA RANCHO PENASQUITOS
FACILITY NUMBER: 374604051
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/17/2024
Section Cited
CCR
87465(a)(2)
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Incidental Medical and Dental Care.A plan for incidental medical...care shall be developed...shall encourage routine medical...care...assistance...obtaining ...care...shall provide assistance in...medical...needs...includes transportation...medical...facility which will meet...resident's...need...or make arrangements...This requirement was not met as evidenced by:

This is an amended report dated 2/27/2024.
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Deficiency is cleared. Facility is closed.

This is an amended report dated 3/13/2024.
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Based on interviews and records reviews the licensee did not provide assistance in obtaining or arranging...medical care for one (1) Resident 1 (R1) in care.
This posed an immediate health risk to 1 out of 65 residents in care.

This is an amended report dated 2/27/2024.
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Type A
04/17/2024
Section Cited
CCR
87464(f)(1)
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Basic services shall...include Care and supervision... means...facility assumes...responsibility...ongoing
assistance...without...physical, health, mental health...welfare... endangered. Assistance...personal care. This requirement was not met as evidenced by:

This is an amended version of the original report dated 2/27/2024.
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Deficiency is cleared. Facility is closed.

This is an amended report dated 3/13/2024.
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The licensee did not provide on-going assistance with resident’s physical health, resulting in rapid weight loss and multiple injuries. This posed an immediate health and safety risk to [R1] 1 of 65 residents in care.

This is an amended version of the original report dated 02/27/2024.
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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: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 08-AS-20210426094317
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: ATRIA RANCHO PENASQUITOS
FACILITY NUMBER: 374604051
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/17/2024
Section Cited
CCR
87211(a)(1)(D)
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Reporting Requirements...each Licensee shall furnish licensing(1) A... report shall be submitted... licensing agency…within seven days…Any incident which threatens the welfare, safety, or health of any resident…
This requirement was not met as evidenced by:
This is an amended report dated 2/27/2024.
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Deficiency is cleared. Facility is closed.

This is an amended report dated 3/13/2024.
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Based on record reviews and interviews, staff did not submit a written report regarding Resident’s 1 [R1] injury to Licensing
This posed a potential personal health risk to 1 out of 65 residents in care.

This is an amended report dated 2/27/2024.
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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: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5