374604057-10-26-2023-08-AS-DPOL-CX5N37-20231031100553

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604057
Report Date: 10/26/2023
Date Signed: 10/26/2023 08:32:18 AM

Unsubstantiated

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
06/02/2023 and conducted by Evaluator Renita Hall

COMPLAINT CONTROL NUMBER: 08-AS-20230602150751

FACILITY NAME:	PLATEAU VILLAGE MEMORY CARE		FACILITY NUMBER:	374604057
ADMINISTRATOR:	AYERSMAN, JENNIE		FACILITY TYPE:	740
ADDRESS:	4960 MILLS STREET		TELEPHONE:	(619) 644-1100
CITY:	LA MESA	STATE: CA	ZIP CODE:	91941
CAPACITY:	0	CENSUS:	DATE:	10/26/2023
		UNANNOUNCED	TIME BEGAN:	10:12 AM
MET WITH:			TIME COMPLETED:	10:13 AM

ALLEGATION(S):

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Staff failed to administer residents' medication as prescribed
Untrained staff
Staff failed to meet residents' medical needs

INVESTIGATION FINDINGS:

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On June 2, 2023, a complaint was received regarding staff members failing to administer residents' medication as prescribed, untrained staff, and staff failing to meet residents' medical needs. The purpose of this investigation was to determine the validity of the allegations and take appropriate actions if necessary.

The following documents were reviewed as part of the investigation: Medication records, Staff training records, Residents' medical records, and Incident reports.

Allegation 1: Staff failed to administer residents' medication as prescribed. The investigation revealed that there were no instances where staff members failed to administer medication as prescribed. There were no incidents reports that indicated a widespread issue. All medications are filled via electronically and medication showed given as prescribed on Medication Administration Report (MAR).
Continued on 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Renita Hall	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023

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-20230602150751

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: PLATEAU VILLAGE MEMORY CARE	FACILITY NUMBER: 374604057
	VISIT DATE: 10/26/2023

NARRATIVE

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Allegation 2: Untrained staff. The investigation found that staff member had proper training in administering medication and meeting residents' medical needs.

Allegation 3: Staff failed to meet residents' medical needs. The investigation revealed that there were no instances where staff members failed to meet residents' medical needs.

Based on the findings of this investigation, the allegations of staff failing to administer residents' medication as prescribed, untrained staff, and staff failing to meet residents' medical needs were found to be un-substantiated. A finding that is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

A copy of this report and Licensee's Rights (LIC 9058 03/22) were mailed to the last known address for the facility.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Renita Hall	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023

LIC9099 (FAS) - (06/04)

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