374604063-5-9-2024-08-AS-SJAB-D5JVZH-20240523165245

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604063
Report Date: 05/08/2024
Date Signed: 05/09/2024 12:30:12 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
04/12/2024 and conducted by Evaluator Amy Domingo

COMPLAINT CONTROL NUMBER: 08-AS-20240412163346

FACILITY NAME:	MESAVIEW SENIOR ASSISTED LIVING		FACILITY NUMBER:	374604063
ADMINISTRATOR:	GENOVEVA GUERRERO		FACILITY TYPE:	740
ADDRESS:	7971 CULOWEE STREET		TELEPHONE:	(619) 466-0253
CITY:	LA MESA	STATE: CA	ZIP CODE:	91942
CAPACITY:	30	CENSUS: 28	DATE:	05/08/2024
		UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Genoveva Guerrero Administrator		TIME COMPLETED:	11:12 AM

ALLEGATION(S):

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Staff restrained a resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to deliver findings in the above complaint allegation. LPA identified herself and discussed the purpose of the visit with Administrator Genoveva Guerrero.

On April 12, 2024 Community Care Licensing (CCL) received a complaint alleging staff restrained a resident. During the investigation, LPA Domingo conducted a facility inspection, collected pertinent records, and conducted interviews.

According to allegations received, Outside Source 1 (OS1), (Please refer to LIC811 confidential names list), observed Resident 1 (R1) with a gait belt wrapped around R1's wheelchair and around the resident to prevent the resident from getting out of the wheelchair.

Continue on LIC9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Amy Domingo	TELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2024

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 3

Control Number 08-AS-20240412163346

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: MESAVIEW SENIOR ASSISTED LIVING	FACILITY NUMBER: 374604063
	VISIT DATE: 05/08/2024

NARRATIVE

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Continued from LIC9099

On April 18, 2024 LPA Domingo interviewed Staff 1 (S1) and S1 stated that S1 does not recall the gait belt wrapping around R1's wheelchair including R1's body. S1 stated that the gait belt is used to help reposition and transfer R1 and is sometimes left on R1's waist because R1 has a history of bending down to remove anything on his feet (Socks, shoes, and slippers). S1 verified that S1 did participate in the care plan meeting on April 12, 2024.

On May 6, 2024 LPA Domingo interviewed Outside Source 2 (OS2) and OS2 stated that there was not a gait belt wrapped around R1's wheelchair and body the day of the care plan meeting on April 12, 2024.

On May 6, 2024 LPA Domingo interviewed Outside Source 3, (OS3) and OS3 stated that OS3 did observe the gait belt wrapped around the wheelchair and waist of R1. OS3 stated that prior to the meetings conclusion OS3 completed a training with the people present at the care plan meeting and reviewed the health and safety reasons to not wrap a gait belt around a person and the wheelchair to prevent the person from falling.

On May 7, 2024 LPA Domingo interviewed Outside Source 4 (OS4) and OS4 verified that there was a gait belt wrapped around the wheelchair and waist of R1. OS4 concurred with OS3 that a training with the staff present at the care plan conference to review the health and safety reasons to not use the gait belt as a restraint.

LPA Domingo attempted to interview other residents in care, but due to their limited cognitive ability no credible information could be attained.

Based on interviews and observations a preponderance of evidence exists to support the allegation that staff restrained a resident. The allegation is therefore substantiated. A deficiency is cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). An exit interview was conducted with Administrator Genoveva Guerrero, to whom a copy of this report, LIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to Administrator Genoveva Guerrero

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Amy Domingo	TELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2024

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20240412163346

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: MESAVIEW SENIOR ASSISTED LIVING	FACILITY NUMBER: 374604063
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/08/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/08/2024 Section Cited CCR 80072(a)(3)	1 2 3 4 5 6 7	Personal Rights. Each clients has the right to be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.	1 2 3 4 5 6 7	The licensee scheduled an in service on how to use a gait belt. Which was held on 4/24/24 The training material and sign in sheet was provided to CCLD on 5/8/24
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: On 4/12/24 1 out of 29 residents was observed with a gait belt around the wheelchair and body. The gait belt around the wheelchair and body was a restraint and a violation of the resident's personal rights. This poses a potential safety risk to clients 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: Simon Jacob	TELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Amy Domingo	TELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2024

LIC9099 (FAS) - (06/04)

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