374604057-7-15-2020-08-AS-SJAB-BRZQ3V-20200730114921

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604057
Report Date: 07/15/2020
Date Signed: 07/15/2020 02:17:50 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
04/17/2020 and conducted by Evaluator Robbie Jackson

COMPLAINT CONTROL NUMBER: 08-AS-20200417162344

FACILITY NAME:	ELMCROFT OF LA MESA		FACILITY NUMBER:	374604057
ADMINISTRATOR:	HEBNER, WES		FACILITY TYPE:	740
ADDRESS:	4960 MILLS STREET		TELEPHONE:	(619) 644-1100
CITY:	LA MESA	STATE: CA	ZIP CODE:	91941
CAPACITY:	56	CENSUS: 21	DATE:	07/15/2020
		UNANNOUNCED	TIME BEGAN:	12:50 PM
MET WITH:	Wes Hebner, Administrator		TIME COMPLETED:	01:25 PM

ALLEGATION(S):

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Licensee did not follow universal precautions.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Robbie Jackson delivered the findings via virtual to a complaint investigation. Virtual visits are being conducted due to COVID-19. LPA spoke with Administrator, Wes Hebner, and explained the purpose of the call.

LPA interviewed staff as well as outside sources, LPA also reviewed and obtained documents from outside sources.

On 4/24/20, the department received a complaint alleging the facility is not following universal precautions by not providing proper PPE equipment in caring for positive covid-19 residents.
Interviews revealed that all staff have been provided PPE to care for Covid-19 residents as well as caring for other residents. Since the facility’s first diagnosis of Covid-19 positive cases, CCL management has made daily calls to the facility as well as provided PPE.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Robbie Jackson	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2020

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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Control Number 08-AS-20200417162344

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: ELMCROFT OF LA MESA	FACILITY NUMBER: 374604057
	VISIT DATE: 07/15/2020

NARRATIVE

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On 5/6/20 a virtual visit was conducted with the Program Clinician Nurse Consultant. During the visit it was observed that the facility had ample amounts of PPE for staff to use.

Based on interviews and documents reviewed and obtained, the allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

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

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Robbie Jackson	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2020

LIC9099 (FAS) - (06/04)

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