374604052-8-26-2020-08-AS-SJAB-BSZUG5-20200831153348

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604052
Report Date: 08/26/2020
Date Signed: 08/26/2020 12:24:21 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
11/21/2019 and conducted by Evaluator Debbie Correia

COMPLAINT CONTROL NUMBER: 08-AS-20191121143006

FACILITY NAME:	NOBLE LIVING III LLC		FACILITY NUMBER:	374604052
ADMINISTRATOR:	GARCIA, NORA		FACILITY TYPE:	740
ADDRESS:	6665 DECANTURE STREET		TELEPHONE:	(619) 542-9269
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92120
CAPACITY:	6	CENSUS: 5	DATE:	08/26/2020
		ANNOUNCED	TIME BEGAN:	11:40 AM
MET WITH:	Administrator, Nora Garcia		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff handled resident in a rough manner.
Staff failed to safeguard resident's personal items.
Staff prevented resident from exiting room.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced video call to deliver findings on the above-mentioned allegations due to COVID-19. LPA identified herself and discussed the purpose of the call and the elements of the allegations with Administrator Nora Garcia.

The Department’s investigation consisted of staff, resident, and outside source interviews. It also consisted of facility, medical, and police records review.

In regards to the above allegations, it was alleged that staff (S1) handled resident #1 (R1, see List of Confidential Names) in a rough manner while being transported from the bed into a wheelchair. It was also alleged during this same incident that S1 was rough in preventing R1 from exiting the bedroom. Interviews with facility staff revealed at the time R1 wanted to exit the bedroom R1 had a bowel accident and S1 was cleaning R1, but was not rough. Interviews with facility staff also revealed no complaints or issues regarding S1.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie Correia	TELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2020

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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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
11/21/2019 and conducted by Evaluator Debbie Correia

COMPLAINT CONTROL NUMBER: 08-AS-20191121143006

FACILITY NAME:	NOBLE LIVING III LLC		FACILITY NUMBER:	374604052
ADMINISTRATOR:	GARCIA, NORA		FACILITY TYPE:	740
ADDRESS:	6665 DECANTURE STREET		TELEPHONE:	(619) 542-9269
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92120
CAPACITY:	6	CENSUS: 5	DATE:	08/26/2020
		UNANNOUNCED	TIME BEGAN:	11:40 AM
MET WITH:	Administrator Nora Garcia		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Facility failed to report suspected abuse.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced video call to deliver finding on the above-mentioned allegation due to COVID-19. LPA identified herself and discussed the purpose of the call and the elements of the allegation with Administrator Nora Garcia.

The Department’s investigation consisted of staff, resident, and outside source interviews. It also consisted of facility, medical records review.

It was alleged facility staff failed to report an abuse accusation made by the RP on 10/31/2019. A review of medical records and a Special Incident Report sent to Licensing revealed facility staff reported the incident on 10/31/19, the same day the accusation was reported. Based on medical and facility records the above allegation is determined to be unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

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

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie Correia	TELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2020

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

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 08-AS-20191121143006

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 III LLC	FACILITY NUMBER: 374604052
	VISIT DATE: 08/26/2020

NARRATIVE

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Interviews with residents corroborated that S1 is very gentle, caring and considered one of the best care givers at the facility. R1 was sent to the hospital for a full examination as a result of the accusation in which medical records revealed no injuries or bruising. R1 tested positive for a urinary tract infection (UTI) and side effects associated with the diagnosis include confusion and disorientation. R1’s physician’s report also revealed a diagnosis of dementia which could contribute to the confusion.

It was also alleged staff failed to safeguard resident’s personal items. Interviews with residents revealed no complaints regarding losing any personal items. A review of the San Diego Police Report and documentation of communication between the Licensee and Reporting Party (RP) revealed the presence of R1’s list of personal property at the time of discharge.

It was alleged facility staff do not respond to communication from resident’s family in a timely manner. Interviews with residents and outside sources revealed no complaints regarding communication with facility staff. There were copious amounts of emails LPA Correia observed of communication between staff and the R1’s family member which revealed realistic response times to family inquiries while caring for other residents. Due to lack of corroborating evidence, the findings regarding the above allegations were established to be unsubstantiated. This finding means although the allegations may have happened or could be valid, there is not a preponderance of evidence to prove that the alleged violations occurred.

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

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie Correia	TELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2020

LIC9099 (FAS) - (06/04)

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