374604103-12-7-2021-08-AS-DPOL-CABMZN-20220103090326

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604103
Report Date: 12/07/2021
Date Signed: 12/07/2021 01:23:25 PM

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
03/29/2021 and conducted by Evaluator Marisela Garcia-Centeno

COMPLAINT CONTROL NUMBER: 08-AS-20210329114514

FACILITY NAME:	SIENNA AT OTAY RANCH SENIOR LIVING		FACILITY NUMBER:	374604103
ADMINISTRATOR:	REBECCA WILLIAMS		FACILITY TYPE:	740
ADDRESS:	1290 SANTA ROSA DR		TELEPHONE:	(619) 550-4521
CITY:	CHULA VISTA	STATE: CA	ZIP CODE:	91913
CAPACITY:	0	CENSUS:	DATE:	12/07/2021
		ANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:			TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Unlawful Eviction

INVESTIGATION FINDINGS:

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The purpose of this report is to deliver findings of a complaint that was filed with Community Care Licensing on March 29, 2021. Licensing Program Analyst (LPA) Marisela Garcia-Centeno attempted to contact the former Licensee and/or Administrator to no avail due to facility closure on August 25,2021.

Investigation by the Department consisted of interviews with staff, outside sources, review of records, and a tour of the facility. It was alleged that Resident R1 was presented with an unlawful eviction by the Administrator. Administrator was provided with the Confidential Names Form (LIC 811) in order to identify R1.

Review of facility records, R1's physician's report and care plan disclosed R1’s cognitive ability as oriented to person, place and time, requiring two (2) person assistance with transfers and incontinence care. It was also indicated that R1 was non-ambulatory with independent mobility while using the electric wheelchair and was able to advocate for themselves and made all decisions regarding medical needs.

Continue to 9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: John Rante	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno	TELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2021

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-20210329114514

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: SIENNA AT OTAY RANCH SENIOR LIVING	FACILITY NUMBER: 374604103
	VISIT DATE: 12/07/2021

NARRATIVE

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Per review of R1’s records and from interviews with facility Administrator and R1’s responsible party it was indicated that R1’s POA signed R1’s Admission Agreement and was responsible for handling R1’s finances.

Review of facility case notes and incident report LIC624 disclosed that on January 21, 2021, R1 had a fall which resulted in a pelvic fracture. It was determined through interviews with outside sources and review of facility records that the facility staff was not culpable nor negligent for R1's fall. R1 was transferred to the hospital to receive immediate medical attention. After surgery R1 was transferred to a skilled nursing facility for rehabilitation. On March 26, 2021 facility staff conducted an assessment and evaluation of R1 at the skilled nursing facility to determine if the facility would be able to continue to meet R1's needs when they were discharged from the skilled nursing facility. Based on interviews with facility staff and outside sources it was determined that after the evaluation was conducted on March 26, 2021, the Administrator verbally informed R1 during a telephone conversation that they would not be accepted back at the facility because the facility could no longer meet R1's needs with transfers. A review of R1’s Milestone Assessments indicated that R1’s care needs for transfers changed from the time of admission (9/25/2019), R1 required one (1) person ambulatory assist, and one (1) person or standby assist for transfers. At a milestone evaluation (12/10/2020) prior to the fall, R1 required two (2) person assist when transferring, two (2) person assist with toileting assistance during the day. According the assessment/evaluation completed on March 26, 2021, R1 required max two (2) person for transfers with gait belt to stand, then one (1) person standby using a platform walker. It was also confirmed during an interview with Administrator that they verbally notified R1 that they could not return to the facility because they could no longer meet R1’s needs for transfers. It was also confirmed by the Administrator that no written notice was given to R1 during the conversation nor afterward. On April 25, 2021, a new placement was arranged by the skilled nursing facility and R1 is currently residing at a different facility. Based on the statements from facility Administrator and corroborating interviews with facility staff and outside sources it was determined that the Administrator verbally informed resident that they would not be accepted back at the facility without providing a formal 30-day written notification, therefore, providing an unlawful notice of eviction. Consequently, this allegation is deemed to be substantiated.

No exit interview was conducted due to facility closure. A copy of this report, along with Licensee Rights (LIC 9058 01/16), were mailed via certified U.S. mai to the last mailing address on file.

SUPERVISOR'S NAME: John Rante	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno	TELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2021

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20210329114514

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: SIENNA AT OTAY RANCH SENIOR LIVING	FACILITY NUMBER: 374604103
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/07/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/07/2021 Section Cited CCR 87224(c)	1 2 3 4 5 6 7	The licensee shall, in addition to either serving the required thirty (30) days’ notice… on the resident, notify or mail a copy of the notice to quit to the resident's responsible person. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Facility closed on 8/25/2021, R1 was relocated prior to the closure. No plan of correction required.
	8 9 10 11 12 13 14	Based on records review and interviews, the licensee did not serve a 30-days’ notice-to-quit to 1 of the 69 residents (Resident #1), which posed a potential personal rights risk to resident 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: John Rante	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno	TELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2021

LIC9099 (FAS) - (06/04)

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