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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604062
Report Date: 09/08/2021
Date Signed: 09/08/2021 10:58:27 AM



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
09/02/2020 and conducted by Evaluator Elizabeth Hamilton
COMPLAINT CONTROL NUMBER: 08-AS-20200902143359
FACILITY NAME:ELMCROFT OF POINT LOMAFACILITY NUMBER:
374604062
ADMINISTRATOR:SHEARER, KELLIEFACILITY TYPE:
740
ADDRESS:3423 CHANNEL WAYTELEPHONE:
(619) 224-7300
CITY:SAN DIEGOSTATE: CAZIP CODE:
92110
CAPACITY:60CENSUS: 44DATE:
09/08/2021
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Business Office Coordinator, Grace RuizTIME COMPLETED:
09:40 AM
ALLEGATION(S):
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Facility did not release resident's records to designated representative
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Elizabeth Hamilton conducted an unannounced complaint investigation visit at the facility. LPA identified herself, was granted access to the facility and met with Business Office Coordinator, Grace Ruiz. LPA explained the purpose of the visit, which was to deliver findings for the above allegation.

It was alleged that on August 28, 2020, a formal request for Resident 1’s (R1 See LIC 811 Confidential Names List) records from the facility was made by the designated representative. Interviews with Executive Director and outside sources revealed that the facility did not respond to the request until September 11, 2020. Interview statement determined facility staff were unaware of the requirement to provide records promptly within two business days. Records reviewed confirmed the requested records were overnight shipped on September 11, 2020 to the designated representative.
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: 09/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021
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-20200902143359
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: 09/08/2021
NARRATIVE
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The Department has investigated the allegation of facility not releasing resident’s records to designated representative. Based on evidence obtained, including interviews and records reviewed 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 of California Code of Regulations, Title 22, Division 6 Chapter 8, and listed on the 9099D. The Plan of Correction was completed on September 11, 2020.

An exit interview was conducted with Business Officer Coordinator, Ruiz and a copy of this report, LIC 811 and Licensee/Appeals Rights (LIC 9058 01/16) was provided to Executive Director via email. An electronic receipt of confirmation was requested to be sent upon receipt of the documents.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Elizabeth HamiltonTELEPHONE: (619) 929-7590
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20200902143359
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: 09/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/11/2020
Section Cited
HSC
1569.269
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1569.269 Enumerated rights; severability (a)(21) Photocopied records shall be promptly provided, not to exceed two business days… This requirement was not met as evidenced by:
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Executive Director overnight shipped the resident’s records to the designated representative on September 11, 2020. Verification was provided to the Department. The Executive Director reviewed Health and Safety Code 1569(a)(21) and provided a copy to the facility's legal team.
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Based on interviews and records reviewed, licensee did not ensure resident’s records were released to the designated representative promptly. This posed a potential personal rights risk to 1 out of 37 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: 09/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021
LIC9099 (FAS) - (06/04)
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