374604057-10-26-2023-08-AS-DPOL-CX5MWG-20231031095819

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604057
Report Date: 10/26/2023
Date Signed: 10/26/2023 08:39:49 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
02/17/2023 and conducted by Evaluator Renita Hall

COMPLAINT CONTROL NUMBER: 08-AS-20230217091255

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:	10:38 AM
MET WITH:			TIME COMPLETED:	10:39 AM

ALLEGATION(S):

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Facility staff did not keep resident’s room free from odor.
Facility staff did not notify RP of how an incident occurred to resident.

INVESTIGATION FINDINGS:

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On February 17, 2023, a complaint was received alleging that the facility staff did not keep the resident's room free from odor. Additionally, it was claimed that the facility staff failed to notify the responsible party (RP) about an incident involving a resident. This investigation aimed to determine the validity of these allegations.

Interviews were conducted with the facility staff members responsible for maintaining resident rooms and communicating with the RP. The staff members denied any knowledge of odor issues in the resident's room or failure to notify the RP about an incident.

Reporting Party (RP): The RP was interviewed to gather their perspective on the alleged incidents. The RP confirmed that they were not informed about any odor issues or an incident involving the resident. When asked if they notice a smell prior to resident moving into the room? RP stated, they did not notice a smell prior to move in.
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-20230217091255

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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Other residents and staff members were interviewed to gather additional information. No witnesses reported any knowledge of odor issues or failure to notify the RP.

The resident's room was thoroughly inspected for any signs of odor. The investigation found no evidence of foul odor or poor cleanliness in the room. The room appeared to be well-maintained and free from any noticeable smells.

The facility's incident reports and communication logs were reviewed to determine if any incident involving the resident had occurred. No incident related to the resident was documented during the specified period.

Based on the interviews conducted, room inspection, and review of incident documentation, the allegations made against the facility staff are un-substantiated. There was no evidence to support the claim that the facility staff did not keep the resident's room free from odor or failed to notify the RP about an incident involving the resident.

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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