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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604062
Report Date: 03/16/2023
Date Signed: 03/16/2023 10:09:34 AM

Substantiated


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
06/08/2020 and conducted by Evaluator Elizabeth Hamilton
COMPLAINT CONTROL NUMBER: 08-AS-20200608125820
FACILITY NAME:ELMCROFT OF POINT LOMAFACILITY NUMBER:
374604062
ADMINISTRATOR:KAREN ROPERFACILITY TYPE:
740
ADDRESS:3423 CHANNEL WAYTELEPHONE:
(619) 224-7300
CITY:SAN DIEGOSTATE: CAZIP CODE:
92110
CAPACITY:60CENSUS: 39DATE:
03/16/2023
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Business Office Manager, Grace RuizTIME COMPLETED:
10:10 AM
ALLEGATION(S):
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Residents are inadequately clothed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Elizabeth Hamilton conducted an unannounced complaint investigation visit at the facility. LPA was greeted at the front entrance by Receptionist, Laura Cano and granted entry after identifying herself. Business Office Manager, Grace Ruiz arrived during the visit. LPA explained the purpose of the visit which was to deliver findings for the above allegation.

The Department’s investigation consisted of record reviews, interviews with staff and outside sources.

On June 08, 2020, it was alleged that on or around April 2020 and May 2020, residents were inadequately clothed. More specifically, it was alleged that during the time in question, multiple residents were walking around the facility either without clothing or in their underwear.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Elizabeth HamiltonTELEPHONE: (619) 929-7590
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023
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 6
Control Number 08-AS-20200608125820
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: ELMCROFT OF POINT LOMA
FACILITY NUMBER: 374604062
VISIT DATE: 03/16/2023
NARRATIVE
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Interviews with staff revealed that during the time in question, the facility had a self-reported scabies outbreak and resident’s clothes were taken away to be washed by staff. Some residents were temporarily left with only one outfit. Interviews further revealed that multiple residents who were treated for scabies were left for brief periods unclothed in their rooms. Records reviewed confirmed the Resident Services Director (RSD) at the time instructed the staff to remove the infected residents’ clothes so the prescribed ointment would not rub off. Evidence obtained determined there was a misinterpreted scabies protocol in effect, which resulted in residents being inadequately clothed.

The Department has investigated the allegation above. Based on evidence obtained, the allegation is substantiated which means that the allegation is valid because the preponderance of the evidence standard has been met. A deficiency is cited in accordance with California Code of Regulations, Title 22, Division 6 Chapter 8, and listed on the 9099D.

An exit interview was conducted with Business Office Manger, Ruiz, a plan of correction was jointly developed, and a copy of this report, LIC 9099D and Licensee/Appeals Rights (LIC 9058 01/16) was provided.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Elizabeth HamiltonTELEPHONE: (619) 929-7590
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 08-AS-20200608125820
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: ELMCROFT OF POINT LOMA
FACILITY NUMBER: 374604062
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/16/2023
Section Cited
CCR
87468.1
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87468.1 Personal Rights of Residents in All Facilities (12) To wear their own clothes; to keep and use their own personal possessions…. This requirement was not met as evidenced by:
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Business Office Manager stated RSD’s employment was terminated and all facility staff during the time in question received a Personal Rights training from an outside vendor. Verification of topics covered and sign in sheet will be provided to the department by 03/23/2023.
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Based on interviews and records reviewed, Licensee did not ensure residents were adequately clothed. This posed a potential personal rights risk to 18 out of 46 residents in care.
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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 PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Elizabeth HamiltonTELEPHONE: (619) 929-7590
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
06/08/2020 and conducted by Evaluator Elizabeth Hamilton
COMPLAINT CONTROL NUMBER: 08-AS-20200608125820

FACILITY NAME:ELMCROFT OF POINT LOMAFACILITY NUMBER:
374604062
ADMINISTRATOR:KAREN ROPERFACILITY TYPE:
740
ADDRESS:3423 CHANNEL WAYTELEPHONE:
(619) 224-7300
CITY:SAN DIEGOSTATE: CAZIP CODE:
92110
CAPACITY:60CENSUS: DATE:
03/16/2023
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Business Office Manager, Grace RuizTIME COMPLETED:
10:10 AM
ALLEGATION(S):
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Residents developed pressure injuries while in care.
Licensee did not arrange for medical care to treat scabies.
Staff not affording residents privacy while taking showers.
Facility was unsanitary.
Residents sustained unexplained bruising while in care.
Staff did not provide incontinence care.
Staff restrained residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Elizabeth Hamilton conducted an unannounced complaint investigation visit at the facility. LPA was greeted at the front entrance by Receptionist, Laura Cano and granted entry after identifying herself. Business Office Manager, Grace Ruiz arrived during the visit. LPA explained the purpose of the visit which was to deliver findings for the above allegations.

The Department’s investigation consisted of record reviews, interviews with staff and outside sources.

On June 08, 2020, it was alleged that on or around April 2020 and May 2020, residents developed pressure injuries while in care. More specifically, it was alleged that multiple residents had “burrowing wounds” as a result of skin tears and adequate care was not provided for them.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Elizabeth HamiltonTELEPHONE: (619) 929-7590
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 08-AS-20200608125820
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: ELMCROFT OF POINT LOMA
FACILITY NUMBER: 374604062
VISIT DATE: 03/16/2023
NARRATIVE
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Records reviewed indicated that the residents in question were on Hospice or Home Health during the time in question and were receiving wound care from the Hospice and Home Health Agencies multiple times a week. Records further confirmed the wounds healed over time. Interviews with outside sources revealed there were no concerns for the residents in question. There was insufficient evidence to support this allegation.

It was further alleged that on or around April 2020 and May 2020, Licensee did not arrange for medical care to treat scabies. During the time in question, the facility self-reported a scabies outbreak and multiple residents were treated for the infection. Interviews with staff confirmed the facility had a scabies outbreak and affected residents were treated with an ointment, prescribed by a Physician. Records reviewed confirmed the facility residents were evaluated by a Medical Doctor and received treatment. There was insufficient evidence to support this allegation.

It was further alleged that on or around April 2020 and May 2020, the staff did not afford residents privacy while taking showers. Interviews with staff revealed that facility had communal showers in each of the four hallways. Residents were either bathed by Caregivers, Hospice or Home Health. Most of the time the bathroom doors were closed while residents were showering; however, a few residents did not like the shower doors completely closed. Interviews revealed Caregivers were mindful to still give privacy while assisting with residents with bathing, by leaving the door partially open. There was insufficient evidence to support this allegation.

It was further alleged that on or around April 2020 and May 2020, the facility was unsanitary. More specifically, it was alleged that there were feces smeared on the walls and food in the carpet. Interviews revealed that during the time in question, there were residents who had behaviors of wiping their feces on the walls and residents would drop food on the floor. However, the facility had housekeeping services who would clean the floors and walls daily and as needed. Records reviewed revealed that the facility also hired a cleaning company to assist during the time in question. There was insufficient evidence to support this allegation.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Elizabeth HamiltonTELEPHONE: (619) 929-7590
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 08-AS-20200608125820
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: ELMCROFT OF POINT LOMA
FACILITY NUMBER: 374604062
VISIT DATE: 03/16/2023
NARRATIVE
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It was further alleged that on or around April 2020 and May 2020, residents sustained unexplained bruising while in care. Interviews revealed that many of the resident’s skin was thin and could bruise easily. Records reviewed and interviews revealed there were no concerns with unexplained bruising. There was insufficient evidence to support this allegation.

It was further alleged that on or around April 2020 and May 2020, staff did not provide incontinence care. Interviews with staff indicated that when they started their shift, they checked the residents, which included incontinent care checks. During the time in question, some residents would have a soiled brief and need changing. Residents were routinely checked every two hours or as needed. Interviews further revealed it was unknown if residents were not changed timely or if it was because their incontinence care check fell in the two-hour period. There was insufficient evidence to support this allegation.

It was also alleged that on or around April 2020 and May 2020, staff restrained residents. More specifically, it was alleged that residents were left in their wheelchairs, in locked positions, unable to move from the dining tables for extended periods of time. Interviews revealed that residents who had wheelchairs were positioned at the dining tables for meals and/or activities; however, staff denied the allegation and maintained that their wheelchairs were never locked. Interviews further revealed that many residents were moved to other areas around the facility and some residents would also stay in their rooms for meals and/or activities. There was insufficient evidence to support this allegation.

The Department has investigated the allegations listed above. Based on evidence obtained, including interviews and records reviewed, the above allegations are determined to be unsubstantiated as the Department could not meet the preponderance of the evidence standard. An exit interview was conducted with Business Office Manager Ruiz and a copy of this report and Licensee/Appeals Rights (LIC 9058 01/16) was provided.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Elizabeth HamiltonTELEPHONE: (619) 929-7590
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6