374604057-5-26-2022-08-AS-SJAB-CEXVGJ-20220531162538

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604057
Report Date: 05/26/2022
Date Signed: 05/26/2022 11:02:24 AM

Unsubstantiated

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
04/04/2022 and conducted by Evaluator Vicky Williamson

PUBLIC

COMPLAINT CONTROL NUMBER: 08-AS-20220404134134

FACILITY NAME:	PLATEAU VILLAGE MEMORY CARE		FACILITY NUMBER:	374604057
ADMINISTRATOR:	DIVINA NUNEZ		FACILITY TYPE:	740
ADDRESS:	4960 MILLS STREET		TELEPHONE:	(619) 644-1100
CITY:	LA MESA	STATE: CA	ZIP CODE:	91941
CAPACITY:	56	CENSUS: 35	DATE:	05/26/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Divinia Nunez, Executive Director		TIME COMPLETED:	11:05 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility is under- staffed
Staff are not providing services agreed upon the resident’s admission agreement
Staff are not trained

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

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 Divinia Nunez, Executive Director, and discussed the purpose of the visit.

The Department’s investigation consisted of interviews with staff, responsible parties, and review of records to include staff and resident records. It was alleged that facility is understaffed. It was reported that the facility is understaffed resulting in Resident 1 (R1) not receiving showers, change of clothing or oral hygiene care. A review of records for the month of March indicated caregiver coverage during morning, and evening shift was four caregivers, and one med tech; night shift caregiver coverage was two caregivers and one med tech. A review of records revealed that the facility serves 35 residents.

Continued on an LIC 9099

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Vicky Williamson	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022

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 3

Control Number 08-AS-20220404134134

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: 05/26/2022

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

The Department’s investigation found no confirmable evidence that residents’ hygiene needs were not being met. Interviews conducted with administrator, staff, residents, and responsible parties provided no conclusive evidence to support the allegation.

Interviews with staff revealed that, although staff are occasionally shorthanded due to staff calling out sick, no resident has missed their scheduled shower, change of clothing or oral hygiene care, unless the resident refused. A selection of staff interviewed reported that residents have missed their scheduled shower because facility is understaffed, and other staff not completing their duties during their shift. These interviews provided no verifiable evidence that the residents are not receiving their daily shower, a clothing change or oral hygiene. Interviews with residents did not corroborate the allegation that the facility is understaffed. The Department interviewed nine residents of which four were qualified as competent witnesses. Interviews with residents revealed that staff assist with their showering on their scheduled day, clothing change daily and oral hygiene. Interviews with responsible parties revealed that residents are observed to be clean and well-groomed and free of odors.

It was alleged that staff are not providing services agreed upon in the resident's admission agreement. It was reported that during the month of March 2022, R1 was not provided showers twice per week as agreed upon in the admission agreement. It was reported that R1 has been observed in clothing from the previous day, toiletries have been observed not used and toothbrush bristles observed to be dry. Facility records were reviewed. The Resident Admission Agreement dated February 28, 2022 for R1 notes limited assistance is needed with showering scheduled, two (2) times per week. The Resident Assignment sheet for April 12, 2022, identifies that R1 showers on Tuesday and Thursday during the PM shift. Per Administrator, the Resident Assignment sheets are not kept on file, therefore LPA was unable to obtain assignment sheets for the month of March 2022. Interviews conducted revealed no corroborating evidence that services upon resident’s admission agreement are not being provided. Interview with R1 revealed that staff take good care of her and she enjoys living at the facility.

Continued on an LIC 9099

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Vicky Williamson	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 08-AS-20220404134134

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: 05/26/2022

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

It was also alleged that staff are not trained properly. It was reported that staff are not properly trained on how to perform caregiver duties such as providing resident hygiene needs. Executive Director and staff interview denied the allegation and stated that a caregiver orientation online training is provided at the facility for four days. Staff is also provided a three day on the job training with a staff member on the floor at the facility. Executive Director stated that if staff does not feel comfortable with their initial training, additional training is provided. A review of staff records shows that direct care staff have the appropriate training on file in providing resident care. No corroborating evidence was obtained to provide proof that staff are not properly trained.

Based on record reviews and interviews, allegations are Unsubstantiated. Although the allegations may have occurred or are valid, there is not a preponderance of the evidence to prove the alleged violations occurred. An exit interview was conducted with Divinia Nunez, Executive Director, the Licensee’s Rights (LIC 9058 01/16) along with a copy of this report was provided to Executive Director and the signature on this form confirms receipt of these rights.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Vicky Williamson	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3