374604057-2-27-2024-08-AS-IESA-D2XA2V-20240229225057

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604057
Report Date: 02/27/2024
Date Signed: 02/27/2024 10:41:58 AM

Substantiated

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
04/13/2023 and conducted by Evaluator Renita Hall

COMPLAINT CONTROL NUMBER: 08-AS-20230413161541

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: 0	DATE:	02/27/2024
		UNANNOUNCED	TIME BEGAN:	09:41 AM
MET WITH:	Closed Facility		TIME COMPLETED:	09:50 AM

ALLEGATION(S):

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Facility staff did not arrange medical care for resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Renita Hall sent this report to the former licensee at their last known mailing address via USPS-certified mail and email to deliver the investigation findings for the above allegation. The facility ceased operations on or about June 7, 2023.

On April 13, 2023, the Department received a complaint alleging that the facility staff did not arrange medical care for the resident. LPA conducted a facility tour and collected residents' and personnel records. Interviews were also conducted.

Resident 1 (R1) had been residing at Plateau Village Memory Care since 10/08/2021. R1 was diagnosed with macular degeneration and is vision impaired, but was able to ambulate without the use of an assistive device. R1 used a wheelchair for long distances. R1 experienced confusion due to Alzheimer’s and Dementia. R1 was able to participate in activities and outings.

Continued on 9099C

Substantiated

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: 02/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2024

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-20230413161541

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: 02/27/2024

NARRATIVE

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On 04/09/23, R1 reported pain in the left wrist to Staff 1 (S1) and when asked why they needed medication, R1 informed S1 that they fell in their room earlier that day. S1 checked for any obvious injury and noted pain in R1's left wrist, which was mildly swollen. S1 notified the family and R1 was given pain medication for their wrist and placed back in bed. Staff reported that R1's family requested to monitor R1 for changes and the resident was not sent to the hospital.

On 04/10/23 R1 continued complaining of wrist pain and staff notified the family to check when they could pick up R1 to take them to the hospital. Staff and Interim Executive Director Natalie Carlborg reported that the family requested that staff not send R1 to the hospital due to insurance coverage and out-of-pocket costs. The family told staff they were not in town and would return on 04/12/23 to pick up R1 and take them to see their physician.

On 04/12/23, the family arrived at the facility at about 1130 hours to transport R1 to the hospital and was told by their physician that R1 sustained a fracture to the left wrist and would require a cast. R1 returned to the facility the same day with no further incident. An interview was conducted on 07/27/23, with the family member who denied asking staff to wait until they could transport R1 to the hospital after sustaining injury from an unwitnessed fall on 04/10/23.

The family advised staff to send R1 to the hospital for non-emergency if they required medical treatment. The family stated they did not keep R1 from seeking medical treatment and staff should have known to send R1 to the hospital.

Based on the Department's investigation the preponderance of evidence standard has been met, therefore the allegation that: Facility staff did not arrange medical care for the residents' Personal Rights is found to be SUBSTANTIATED. California Code of Regulations 87465(2) is being cited on the attached LIC 9099D. An immediate civil penalty of $500 was assessed.

A copy of this report along with Licensee/Appeal Rights (LIC 9058) was mailed via USPS Certified Mail to the former licensee’s mailing address on file.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Renita Hall	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20230413161541

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/27/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/20/2024 Section Cited HSC 87465(2)	1 2 3 4 5 6 7	87465 (2)The licensee shall provide assistance in meeting necessary medical and dental needs........ In providing transportation the licensee shall do so directly or make arrangements for this service.	1 2 3 4 5 6 7	“An immediate civil penalty in the amount of $500 was issued during today’s visit
	8 9 10 11 12 13 14	A civil penalty in the amount of $500 was assessed per Health and Safety Code 1569.49(c)(1), for a violation that the Department determined resulted in an injury of R1. Determination of Civil Penalties under Health and Safety Code Section 1569.49 are pending and under review by the Program Administrator of the Community Care Licensing Division.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
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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: Denise Powell	TELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Renita Hall	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024

LIC9099 (FAS) - (06/04)

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