374604063-5-9-2024-08-AS-SJAB-D5PVVR-20240528164647

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604063
Report Date: 05/08/2024
Date Signed: 05/09/2024 12:28:50 PM

Unsubstantiated

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
05/02/2024 and conducted by Evaluator Amy Domingo

COMPLAINT CONTROL NUMBER: 08-AS-20240502165909

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:	11:15 AM
MET WITH:	Genoveva Guerrero Administrator		TIME COMPLETED:	12:56 PM

ALLEGATION(S):

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Staff did not meet resident's needs

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 May 1, 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.

On May 8, 2024 LPA interviewed Resident 1 (R1) and R1 stated that R1 feels that staff do meet resident's needs. R1 stated that the facility staff address R1 needs in a timely manner. R1 stated that R1 has challening days but that does not reflect the care the facility staff provide for R1 or other residents. R1 stated that the facility has a communication log that assist with understanding R1's needs and R1 agrees that the communication log works well.

Unsubstantiated

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 5

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
05/02/2024 and conducted by Evaluator Amy Domingo

COMPLAINT CONTROL NUMBER: 08-AS-20240502165909

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:	11:15 AM
MET WITH:	Genoveva Guerrero Administrator		TIME COMPLETED:	12:56 PM

ALLEGATION(S):

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Resident's call button did not work

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 May 1, 2024 Community Care Licensing (CCL) received a complaint alleging residents call button did not work. During the investigation, LPA Domingo conducted a facility inspection, collected pertinent records, and conducted interviews.

On May 6, 2024 LPA Domingo was provided with a tour of the facility. LPA Domingo requested to observe how the call light system works. Staff 1 (S1) pulled a call light in a room and the call light panel did not light up indicating that the call light was pulled. Staff 2 (S2) pulled the call light in another room and the panel did not light up indicating that the call light was pulled. The facility was unaware that the call light panel and system was not in working order.

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: 2 of 5

Control Number 08-AS-20240502165909

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 May 8, 2024 Resident 1 (R1) was interviewed and R1 stated that there was a possibility that R1 may have broken the call light in R1's room but verbalized that R1 prefers to not have a call light. S1 and R1 both agreed to have a smart button that R1 has on her person to alert staff if R1 needs staff assistance. R1 is the only resident with a smart button the other residents have a call light in the rooms to alert staff if there is a need for assistance.

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 does exists to support the allegation that residents call light did not work. 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.

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)

Page: 3 of 5

Control Number 08-AS-20240502165909

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 06/07/2024 Section Cited CCR 87303(i)(1)	1 2 3 4 5 6 7	Facilities shall have signal systems...All facilities licensed for 16 or more...shall have a signal system which shall: Operate from each resident's living unit. Transmit a visual and/or auditory signal to a central staffed location...loud enough to summon staff. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee agreed to do "Call light checks" every week and will conduct a management training regarding Call light system and will provide proof of training to LPA by POC due date of 6/7/24
	8 9 10 11 12 13 14	Based on LPA direct observation the licensee did not have a functional signal system for 27 of 28 persons in care which posed a potential health and safety risk to persons 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)

Page: 4 of 5

Control Number 08-AS-20240502165909

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

Staff 1 (S1) was interviewed and S1 provided the care plans that the staff are working on to provide better assistance with R1's needs. S1 provided the staff schedule and there is appropriate staffing for the residents needs. Outside Source 1 (OS1) was interviewed and there has not been any complaints regarding residents needs are not being met. Outside Source 2 (OS2) was interviewed and OS2 has not observed residents needs not being attended to.

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 does exists to support the allegation that staff are not meeting residents needs. The allegation is therefore unsubstantiated. An exit interview was conducted with Administrator Genoveva Guerrero, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.

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)

Page: 5 of 5