<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604057
Report Date: 03/15/2024
Date Signed: 04/16/2024 12:57:51 PM

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
02/22/2022 and conducted by Evaluator Marisela Garcia-Centeno
COMPLAINT CONTROL NUMBER: 08-AS-20220222133817
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:0CENSUS: 0DATE:
03/15/2024
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Report mailed due to facility closure June 7, 2023TIME COMPLETED:
04:40 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not seek timely medical attention for a resident resulting in a serious injury
Staff did not notify responsible party of resident's change of condition
Staff did not observe resident's significant weight loss


This is an amended version of the original report created on 3/15/2024
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA), Marisela Garcia-Centeno, sent this report to the former Licensee's last known mailing address via USPS certified mail to deliver the investigation findings for the above allegation. The facility was closed on June 7, 2023.

The Department investigated the above-listed complaint allegations. The investigation consisted of an inspection of the facility, observations, multiple interviews with staff and outside sources, and a detailed review of relevant records.

On February 22, 2022, Community Care Licensing (CCL) received a complaint alleging that staff did not seek timely medical attention for a resident (R1), [a LIC 811 Confidential Names List was provided to staff to identify the resident], when there was a change in condition. It was specifically alleged that on or about January 7, 2022, R1 had an unwitnessed fall.
(continue at LIC9099C) Note: This is an amended version of the original report created on 3/15/2024
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jennifer LottTELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Marisela Garcia-CentenoTELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024
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-20220222133817
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: 03/15/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
(Continue from LIC9099)

A detailed review of R1’s medical records and service care plan indicated that R1 was ambulatory and had no history of falls or being a fall risk. R1 was diagnosed with dementia and required medication management. During staff interviews, it was indicated that after the fall incident, although R1 was able to get up with assistance, they were not able to walk without pain. A review of the incident report completed on January 7, 2022, indicated that R1 was unable to walk without limping or grimacing in pain. Staff indicated that the R1’s responsible party was informed of R1’s fall and instructed staff to monitor R1’s condition and that they would schedule an appointment with R1’s primary care physician (PCP). A review of R1’s medical records indicated that it wasn’t until February 16, 2022, almost six (6) weeks after the fall that R1’s x-rays and CAT scan confirmed R1 had sustained a left femoral neck fracture. R1 was hospitalized and then transferred to a skilled nursing facility for rehabilitation.

A review of R1’s service care plan indicated that R1 was ambulatory since they moved into the facility in August 2018. In addition, during staff interviews, it was indicated that R1 had no trouble walking around the facility unassisted. Based on records review and interviews with staff, there was sufficient evidence to support the allegation that staff did not monitor R1's change in condition and failed to follow protocol to provide immediate medical attention to meet R1’s needs. Staff failed to take immediate action by calling 911 or arranging medical care when R1 was not able to walk without pain after the fall.

It was also alleged that staff did not notify the responsible party of resident’s change of condition. After the fall incident, R1 became wheelchair-bound and this change in condition was not communicated to R1’s PCP nor R1’s responsible party. Based on records review, and multiple interviews with staff and outside sources, there was sufficient information and written documentation supporting that staff was negligent and minimized the injury when reporting the incident to R1’s responsible party.

In addition, it was alleged that staff did not observe resident’s significant weight loss. A review of R1’s medical records and interviews with outside sources indicated that R1 had a significant weight loss of 16 lbs. within a short period.

(Continue at LIC9099C)
SUPERVISOR'S NAME: Jennifer LottTELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Marisela Garcia-CentenoTELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 08-AS-20220222133817
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: 03/15/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
(Continue at LIC9099C)

During interviews, facility management stated that they were not aware that R1 had a significant weight loss because direct staff did not report the weight scale had been broken for some time and they were not monitoring residents’ weight as required. Facility management indicated that it was standard protocol to weigh all residents at least monthly or more often as needed to meet residents’ needs. Management indicated that due to staffing shortages during the COVID-19 pandemic, the facility hired a variety of caregivers from outside agencies which resulted in miscommunication and inconsistencies in the care and supervision of residents.

The Department has investigated the above-mentioned allegations and has found that there was sufficient evidence to corroborate the allegations. Therefore, these allegations are deemed to be substantiated. A substantiated finding means the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies were cited per Title 22, Division 6, Chapter 8 of the California Code of Regulations and are listed on LIC 9099-D. A plan of corrections was not developed as the facility closed operations in June 2023. 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.

A copy of this report along with LIC421 IM - Civil Penalty, LIC811 Confidential Name List, and Licensee/Appeal Rights (LIC9058 03/22) was mailed to the last known Licensee’s address due to the closure of the facility in June 2023.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Marisela Garcia-CentenoTELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 08-AS-20220222133817
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: 03/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/15/2024
Section Cited
CCR
87465(a)(1)
1
2
3
4
5
6
7
87465(a)(1) Incidental Medical and Dental Care. The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
No plan of correction was developed because the facility ceased operations in June 2023.
8
9
10
11
12
13
14
Based on interviews and records review, the licensee did not ensure the facility staff arranged medical care appropriate to R1’s condition in 1 of 34 persons in care which posed an immediate Health and Personal Rights risk to persons in care.
8
9
10
11
12
13
14
Type B
03/15/2024
Section Cited
CCR
87211(a)(1)(B)
1
2
3
4
5
6
7
87211(a)(1)(B) Reporting Requirements
A written report shall be submitted ….to the person responsible for the resident within seven days of …..any serious injury ….. occurring while the resident is under facility supervision. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Based on interviews and record review, the licensee did not report to the person responsible for R1 when R1 sustained a serious injury. This posed a potential health risk to (1) of (34) residents in care.
8
9
10
11
12
13
14
No plan of correction was developed because the facility ceased operations in June 2023.
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 PowellTELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Marisela Garcia-CentenoTELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 08-AS-20220222133817
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: 03/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/15/2024
Section Cited
CCR
87466
1
2
3
4
5
6
7
87466 Observation of the Resident
The licensee shall ensure that residents are regularly observed for changes in physical, …..such as unusual weight gains or losses …..the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person. This requirement was not met as evidenced by.

1
2
3
4
5
6
7
No plan of correction was developed because the facility ceased operations in June 2023.
8
9
10
11
12
13
14
Based on interviews and records review, the licensee did not observe and report changes in R1’s unusual weight loss to R1’s responsible person. This posed a potential health risk to (1) of (34) residents in care
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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 PowellTELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Marisela Garcia-CentenoTELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 7
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
02/22/2022 and conducted by Evaluator Marisela Garcia-Centeno
COMPLAINT CONTROL NUMBER: 08-AS-20220222133817

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:0CENSUS: 0DATE:
03/15/2024
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Report mailed due to facility closure June 7, 2023TIME COMPLETED:
04:40 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff smoked marijuana at the facility
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA), Marisela Garcia-Centeno, sent this report to the former Licensee's last known mailing address via USPS certified mail to deliver the investigation findings for the above allegation. The facility was closed on June 7, 2023.

The Department investigated the above-listed complaint allegation. The investigation consisted of observations, a review of relevant records, and interviews with facility staff and outside sources.

On February 22, 2022, Community Care Licensing (CCL) received a complaint alleging that staff smoked marijuana at the facility. It was specifically alleged that two staff members were observed smoking marijuana outside the facility in the smoking area. The dates and/or times of when this occurred or any other examples of similar staff behavior at the facility were not identified.
(Continue at LIC9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Marisela Garcia-CentenoTELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 08-AS-20220222133817
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: 03/15/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
(Continue from LIC9099A)

Based on interviews with multiple staff and outside sources no corroborating evidence was obtained to support the allegation. Facility management indicated that when the incident was reported, an internal investigation was conducted which consisted of employee interviews. Management stated that all staff were drug tested before employment and based on the results of the internal investigation employee drug retesting was not warranted. The Department did not obtain credible information during the investigation from staff or outside sources corroborating this allegation. Interviews with staff indicated they had not seen or witnessed any staff members smoking marijuana or any other illicit drugs.

The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of the evidence has not been met, therefore, this allegation is deemed unsubstantiated.

A copy of this report along with Licensee/Appeal Rights (LIC9058 01/16) was mailed to the last known Licensee’s address due to the closure of the facility in June 2023.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Marisela Garcia-CentenoTELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 7