374604062-6-22-2023-08-AS-DPOL-CTAV8H-20230630161247

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604062
Report Date: 06/22/2023
Date Signed: 06/22/2023 10:28:15 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
05/03/2023 and conducted by Evaluator Renita Hall

COMPLAINT CONTROL NUMBER: 08-AS-20230503162650

FACILITY NAME:	POINT LOMA ESTATES MEMORY CARE		FACILITY NUMBER:	374604062
ADMINISTRATOR:	SHEARER, KELLIE		FACILITY TYPE:	740
ADDRESS:	3423 CHANNEL WAY		TELEPHONE:	(619) 224-7300
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92110
CAPACITY:	60	CENSUS: 0	DATE:	06/22/2023
		UNANNOUNCED	TIME BEGAN:	10:11 AM
MET WITH:	Jennie Ayersman, Executive Director		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Staff did not treat resident with dignity and respect

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Renita Hall conducted an unannounced visit to deliver findings. LPA was allowed entry by the Executive Director Jennie Ayersman. LPA identified herself and disclosed the purpose of the visit and shared findings with the Executive Director Jennie Ayersman.

On May 3, 2023, it was alleged that staff did not treat resident with dignity and respect. The Department investigated the complaint allegation. The investigation consisted of a tour of the facility, interviews with staff, residents, outside sources and records review.

On June 5, staff interviewed stated that they had witnessed and heard two other care staff speaking in Spanish and making fun of residents. The staff comments did not show respect and dignity for residents. The Director acknowledged that she was notified of the incident and had put in place a personnel training on personal rights of residents.

Continued on 9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: John Rante	TELEPHONE: (619) 767-2330
LICENSING EVALUATOR NAME: Renita Hall	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

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-20230503162650

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: POINT LOMA ESTATES MEMORY CARE	FACILITY NUMBER: 374604062
	VISIT DATE: 06/22/2023

NARRATIVE

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Based on the evidence obtained during the complaint investigation, the allegation of staff not treating resident with dignity and respect was found to be SUBSTANTIATED, as there is a preponderance of evidence to prove the alleged violation occurred. An exit interview was conducted; a copy of this report along with Licensee Appeal Rights LIC 9058 (REV 3/22) were provided to the Facility Executive Director and their signature confirms receipt of these document

SUPERVISOR'S NAME: John Rante	TELEPHONE: (619) 767-2330
LICENSING EVALUATOR NAME: Renita Hall	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20230503162650

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: POINT LOMA ESTATES MEMORY CARE	FACILITY NUMBER: 374604062
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/22/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/20/2023 Section Cited CCR 87707(2)(A)(5)	1 2 3 4 5 6 7	Licensees… providing special care, programming, and/or environments for residents with dementia...(2) Direct care staff shall complete at least eight hours of in-service training...(A) A minimum of two of the following training topics shall be covered annually..(5) Promoting resident dignity..	1 2 3 4 5 6 7	facility must verify and submit proof that the training was done— agenda, or sign in sheet, materials? Corrected on May 10, 2023 proof of sign in sheet provided
	8 9 10 11 12 13 14		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: John Rante	TELEPHONE: (619) 767-2330
LICENSING EVALUATOR NAME: Renita Hall	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

LIC9099 (FAS) - (06/04)

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