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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604057
Report Date: 11/15/2022
Date Signed: 11/15/2022 05:06:28 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
09/06/2022 and conducted by Evaluator Vicky Williamson
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20220906121802
FACILITY NAME:PLATEAU VILLAGE MEMORY CAREFACILITY NUMBER:
374604057
ADMINISTRATOR:DIVINA NUNEZFACILITY TYPE:
740
ADDRESS:4960 MILLS STREETTELEPHONE:
(619) 644-1100
CITY:LA MESASTATE: CAZIP CODE:
91941
CAPACITY:56CENSUS: 33DATE:
11/15/2022
UNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Executive Directors Divinia Nunez and Jennie Ayersman TIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Medications are accessible to residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vicky Williamson conducted a complaint visit to deliver findings on the above allegation. LPA was greeted by the receptionist and granted entry into the facility. LPA met with Executive Directors Divinia Nunez and Jennie Ayersman and discussed the purpose of the visit.

The Department’s investigation consisted of a tour of the facility, a review of facility records, resident and outside source records, interviews with staff, residents, responsible parties, and outside sources.
It was alleged that medications are accessible to residents.

It was reported that June 23, 2022, an outside source observed medication on the floor in the dining area of the facility. The medication was observed to be a yellow pill on the floor. Outside source stated that they advised Staff 1 (S1) of the yellow pill that was observed on the floor. It was alleged that S1 picked up the pill and replied “oh.”

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Vicky WilliamsonTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2022
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 7
Control Number 08-AS-20220906121802
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: PLATEAU VILLAGE MEMORY CARE
FACILITY NUMBER: 374604057
VISIT DATE: 11/15/2022
NARRATIVE
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Interviews with a few staff indicated that on occasion medication is observed on the floor in the dining area due to staff walking away from the residents prior to them digesting the medication. Other staff interviewed indicated that they have never observed medication on the floor anywhere at the facility. They indicated that staff always wait until the medication is digested by the residents.

The Department has investigated the above-mentioned allegation that that medications are accessible to residents. Based on interviews conducted with staff, residents, responsible parties, outside sources and documentation obtained from an outside source, the preponderance of the evidence standard has been met. Therefore, the allegation is deemed substantiated.

The deficiency is noted on the attached LIC9099-D and is cited in accordance with the California Code of Regulations, Title 22, Division 6. A copy of this report along with Licensee/Appeal Rights (LIC 9058) was provided to Executive Directors Divinia Nunez and Jennie Ayersman and the signature on this form confirms receipt of these rights.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Vicky WilliamsonTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 08-AS-20220906121802
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: PLATEAU VILLAGE MEMORY CARE
FACILITY NUMBER: 374604057
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/21/2022
Section Cited
CCR
87465(h)(2)
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87465 Incidental Medical and Dental Care h)The following requirements shall apply to medications which are centrally stored: (2)Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored
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Executive Directors and staff will complete a training with an outside source and provide proof of training by POC date.
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medication. The requirement was not met as evidenced by: Based on interviews and documents reviewed, medication is often observed on the floor in the dining area of the facility. This poses a potential safety risk to 56 out 56 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.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Vicky WilliamsonTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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
09/06/2022 and conducted by Evaluator Vicky Williamson
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20220906121802

FACILITY NAME:PLATEAU VILLAGE MEMORY CAREFACILITY NUMBER:
374604057
ADMINISTRATOR:DIVINA NUNEZFACILITY TYPE:
740
ADDRESS:4960 MILLS STREETTELEPHONE:
(619) 644-1100
CITY:LA MESASTATE: CAZIP CODE:
91941
CAPACITY:56CENSUS: 33DATE:
11/15/2022
UNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Executive Directors Divinia Nunez and Jennie Ayersman TIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Resident developed an infection while in care
Facility mismanaged resident's medication
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vicky Williamson conducted a complaint visit to deliver findings on the above allegations. LPA was greeted by the receptionist and granted entry into the facility. LPA met with Executive Directors Divinia Nunez and Jennie Ayersman and discussed the purpose of the visit.

The Department’s investigation consisted of a tour of the facility, a review of facility records, resident and outside source records, interviews with staff, residents, responsible parties and outside sources. A review of records revealed that Resident 1 (R1) [LIC 811 Confidential Names List provided to Executive Directors to identify R1] had dry skin issues upon admission to the facility on 5/17/21 . Interviews reveal that at the time of admission and prior to the hospitalization of R1, the requirements for the treatment of their rash was for staff to monitor, and apply topical cream as needed. Staff were notified to report observations of redness or new issues regarding the rash on R1’s upper torso and arms.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Vicky WilliamsonTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 08-AS-20220906121802
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: PLATEAU VILLAGE MEMORY CARE
FACILITY NUMBER: 374604057
VISIT DATE: 11/15/2022
NARRATIVE
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Interviews and outside source records reviewed during the investigation revealed that R1 was taken to the hospital and hospitalized on 8/8/22 due to swelling of the left elbow. Outside source records reflect that R1 was assessed and diagnosed with left arm cellulitis. Records indicate that R1 was administered medication for over 48 hours with no improvement, it is noted that inflammatory markers became worst. On 8/12/22, R1 was evaluated for Orthopedic surgery. The surgery procedure consisted of an incision and drainage of skin subcutaneous tissue to R1’s left elbow. Copious material was drained from the elbow and sent for a culture. The culture was positive for Methicillin-resistant Staphylococcus aureus (MRSA) ; however, no source of the infection was identified. On August 16, 2022, R1 was discharged from the hospital and transferred to a skill nursing facility due to the MRSA.

Records reviewed provide no evidence to conclude that R1’s medical condition was caused by actions or a lack of care from facility staff.

It was alleged that the facility mismanaged resident's medication. It was reported that R1’s medication was not provided to them due to the facility lost the packaging that the medication was provided to them in. Staff interviewed denied the allegation and stated that the topical cream was not provided to the facility. It was alleged that the medication was provided to the facility two weeks after the medication should have been started. Per review of Medication Administration Report (MAR), R1 began taking the medication on 6/12/22 and it was discontinued on 6/22/22.

Interviews and record review provided no collaborating evidence to determine that R1’s medication was mismanaged.

The Department investigation has found that there is insufficient evidence to determine that the above allegations occurred. Based on interviews and record review, allegations are unsubstantiated. Although the allegations may have occurred or is valid, there is not a preponderance of the evidence to prove the alleged violation occurred.


An exit interview was conducted with Executive Directors Divinia Nunez and Jennie Ayersman to whom a copy of this report and the Licensee's/Appeal Rights (LIC9058 01/16) were provided Executive Directors.

SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Vicky WilliamsonTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 7