374604065-6-28-2022-08-AS-JRAE-CGRUCU-20220728152829

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604065
Report Date: 06/28/2022
Date Signed: 06/28/2022 12:05:45 PM

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
02/07/2020 and conducted by Evaluator Ramon Serrano

COMPLAINT CONTROL NUMBER: 08-AS-20200207101530

FACILITY NAME:	LAS VILLAS DE CARLSBAD		FACILITY NUMBER:	374604065
ADMINISTRATOR:	BLOOM, CHARLIE		FACILITY TYPE:	740
ADDRESS:	1088 LAGUNA DRIVE		TELEPHONE:	(760) 434-7116
CITY:	CARLSBAD	STATE: CA	ZIP CODE:	92008
CAPACITY:	214	CENSUS: 100	DATE:	06/28/2022
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Wesley Lavender		TIME COMPLETED:	12:07 PM

ALLEGATION(S):

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-Neglect/Lack of supervision resulting in serious bodily injury
-Sexual abuse of a resident by an unknown perpetrator

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced visit to deliver investigative findings. LPA was granted entry into the facility and met with Wesley lavender, to whom LPA disclosed the reason for the visit.

Community Care Licensing (CCL) has investigated the above listed complaint allegations. The investigation consisted of review of facility and resident records, interviews with staff and outside agency interviews.

On February 4, 2020, the facility reported to Community Care Licensing (CCL) that a resident (R1) [an LIC 811 Confidential Names List was provided to staff to identify the resident] sustained sexual abuse by an unknown perpetrator. Subsequently it was alleged that neglect/lack of supervision resulted in a sexual assault and attempted rape of R1 on February 4, 2020. Law Enforcement interview with R1 revealed they were woken up around 6am on February 4, 2020, by an unknown man after he moved R1's blankets. (continued on LIC9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Ramon Serrano	TELEPHONE: (619) 458-2583
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2022

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 4

Control Number 08-AS-20200207101530

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: LAS VILLAS DE CARLSBAD	FACILITY NUMBER: 374604065
	VISIT DATE: 06/28/2022

NARRATIVE

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R1 tried to scream, and the man placed his hands on R1’s mouth and told them not to scream or he would hurt R1. The man moved R1’s wheelchair and stood beside R1’s bed pleasuring himself and asked R1 to perform a sexual act.

Interview with staff revealed that on February 4, 2020, at about 6:10am a caregiver was alerted that R1 pushed their pendant button and needed assistance. As the caregiver attempted to open R1’s door the unknown man was pushing against it to prevent her from entering. When she entered the room, she asked the man what he was doing there and struck him several times in the head. The suspect then ran out of the building. R1 advised the caregiver that the suspect tried to rape them, and the caregiver noticed R1’s pajamas and underwear were on the floor at the end of their bed.

Interview with the Executive Director (ED) revealed the incident occurred in the middle of shift change. ED stated that the facility doors open at 6am and close at 7pm. ED also stated that there was no one at the front desk at 6am since the front desk worker starts at 7am. ED agreed that anyone could walk in the facility and no one would see them.

After review of interviews from R1, staff and outside agency, it is evident that the lack of supervision and safety protocols resulted in the attempted rape of R1 and therefore the above allegation is substantiated.

This finding means that the preponderance of the evidence standard has been met and the allegation is valid. Deficiency is cited in accordance with California Code of Regulations, Title 22.

On February 6, 2020, the facility reported to Community Care Licensing an unwitnessed fall which resulted in serious bodily injury of Resident 1 (R1). Subsequently it was alleged that R1 suffered a fall that resulted in subdural hematoma on February 4, 2020. Interview with staff revealed at around 1pm, R1 called out verbally for assistance after falling. Three caregivers went to R1's room and found them on the bathroom floor. R1 advised staff that they fell while brushing their teeth. Staff stated R1 can pull themselves up out of the wheelchair and R1 prefers to do things on their own. Interview with R1 revealed they were in their wheelchair and wheeled themselves to the bathroom, to brush their teeth. When asked why they didn't call anyone for help, R1 stated they wanted to do it on their own. R1 stated the brakes were not engaged on the wheelchair and their hand slipped causing them to fall backwards and hit their head.
(Continued on LIC9099-C)

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Ramon Serrano	TELEPHONE: (619) 458-2583
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 08-AS-20200207101530

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: LAS VILLAS DE CARLSBAD	FACILITY NUMBER: 374604065
	VISIT DATE: 06/28/2022

NARRATIVE

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A review of facility records revealed R1 had a stroke on February 19, 2011, which resulted in a weak left leg. It was also documented that their primary diagnosis was gait instability. R1 had over six unwitnessed falls from August 13, 2019 through February 4, 2020. On February 4, 2020, R1 was admitted to the hospital with a diagnosis of subdural hematoma. Outside agency notes dated February 8, 2020, show that R1 advised hospital staff they had also fallen two other times in the previous week; and both times they fell in the bathroom and hit their head in the same place. Despite the facility documenting all R1’s previous falls and reassessments, no measures were put in place to mitigate future falls or increase supervision. A review of the plan of care dated February 2, 2020, revealed a history of falls but there were no documented objectives to mitigate falls other than reminding resident to call for assistance when transferring.

Based upon interviews conducted and records review, the above allegation is substantiated. This finding means that the preponderance of the evidence standard has been met and the allegation is valid. Deficiency is cited in accordance with California Code of Regulations, Title 22.

Due to the serious nature of the allegations, the Department will review this case for a Civil Penalty per Health and Safety Code section 1569.49(f). An exit interview was conducted with Wesley Lavender and a copy of this report and Licensee/Appeal Rights (LIC 9058) were provided to Wesley Lavender whose signature below confirms receipt of documents.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Ramon Serrano	TELEPHONE: (619) 458-2583
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 08-AS-20200207101530

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: LAS VILLAS DE CARLSBAD	FACILITY NUMBER: 374604065
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/28/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/28/2022 Section Cited CCR 87463(a)	1 2 3 4 5 6 7	The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee will perform quarterly assessments as well as assessments for change in condition triggered by trend in falls or other unsafe behaviors. Care plan will be updated based on the findings via assessment to include increases in safety checks and the possibility of 1 on 1 oversight.
	8 9 10 11 12 13 14	Based on interviews and record review, the licensee did not update the appraisal to note significant changes and did not keep the appraisal accurate in 1 of 100 persons in care (R1) which posed an immediate Health and Safety risk to persons in care.	8 9 10 11 12 13 14
Type A 06/28/2022 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	Residents in all residential care facilities for the elderly shall have all of the following personal rights:To be accorded safe, healthful and comfortable accommodations. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Community has erected an 8 foot tall perimeter fence, accesssed only by staff with a key or remote control. Exterior doors are now disengaed at 8am by staff at the community(no longer automatic) Maintenance staff are present on the community grounds at 6am and perform security sweeps.
	8 9 10 11 12 13 14	Based on interviews, the licensee did not accord safe, healthful and comfortable accommodations for 1 out of 100 persons in care (R1) which posed an immediate Health and Safety risk to persons in care.	8 9 10 11 12 13 14

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 Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Ramon Serrano	TELEPHONE: (619) 458-2583
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2022

LIC9099 (FAS) - (06/04)

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