374604103-11-12-2020-08-AS-IESA-CC42Y8-20220228164818

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604103
Report Date: 11/12/2020
Date Signed: 11/12/2020 03:32:14 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
11/06/2020 and conducted by Evaluator Anna Kennedy

COMPLAINT CONTROL NUMBER: 08-AS-20201106150500

FACILITY NAME:	SIENNA AT OTAY RANCH SENIOR LIVING		FACILITY NUMBER:	374604103
ADMINISTRATOR:	MENDEZ, RUBY GOMEZ		FACILITY TYPE:	740
ADDRESS:	1290 SANTA ROSA DR		TELEPHONE:	(619) 550-4521
CITY:	CHULA VISTA	STATE: CA	ZIP CODE:	91913
CAPACITY:	137	CENSUS: 96	DATE:	11/12/2020
		UNANNOUNCED	TIME BEGAN:	02:16 PM
MET WITH:	Erika Hughes		TIME COMPLETED:	03:32 PM

ALLEGATION(S):

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Employees assisting residents with self-administered medications are not properly trained.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kennedy conducted a complaint visit via a video-calling app due to COVID-19 restrictions to investigate the above allegation. LPA identified herself and stated the purpose of the video-call to Erika Hughes, Administrator.

During the investigation, LPA toured the facility via video calling app, reviewed facility records and conducted interviews.

The allegation is that employees assisting residents with self-administered medications are not properly trained.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Hedgecock	TELEPHONE: (619)767-2329
LICENSING EVALUATOR NAME: Anna Kennedy	TELEPHONE: (619) 997- 4108
LICENSING EVALUATOR SIGNATURE:	DATE: 11/12/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2020

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-20201106150500

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: 11/12/2020

NARRATIVE

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Each employee that assists residents with self-administered medication under Title 22, Division 6 1569.69 must have specific training including a test demonstrating understanding of the specified materials. Interviews and training documentation revealed that none of the staff members who are responsible for assisting residents with self-administered medications had documented training that met the requirements.

LPA found that the preponderance of evidence standard has been met and the allegations are therefore determined to be Substantiated.
A deficiency is cited in accordance to the California Code of Regulations, Title 22 and is on the attached 9099-D

An exit interview was conducted with Erika Hughes, Administrator. via video-call. A copy of this report along with Licensee Rights (LIC9058 01/2016) was provided to Ms. Hughes via email. An electronic response confirms the documents were received.

SUPERVISOR'S NAME: Rebecca Hedgecock	TELEPHONE: (619)767-2329
LICENSING EVALUATOR NAME: Anna Kennedy	TELEPHONE: (619) 997- 4108
LICENSING EVALUATOR SIGNATURE:	DATE: 11/12/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 08-AS-20201106150500

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: 11/12/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/26/2020 Section Cited HSC 1569.69	1 2 3 4 5 6 7	HSC 1569.69 Employees assisting residnets with self-administation of medication; training requiremnets. This requirment was not met as evidenced by:	1 2 3 4 5 6 7	Facility will provide all employees covered under this regulations with all required training, with proper documentation verifying the training.
	8 9 10 11 12 13 14	A review of training documnetation revealed that no employee covered under this regulation has had the required training, posing a potential risk to the health of all of the residnets in care.	8 9 10 11 12 13 14	Facility will provide the documentation to CCL by the POC date.
	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: Rebecca Hedgecock	TELEPHONE: (619)767-2329
LICENSING EVALUATOR NAME: Anna Kennedy	TELEPHONE: (619) 997- 4108
LICENSING EVALUATOR SIGNATURE:	DATE: 11/12/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2020

LIC9099 (FAS) - (06/04)

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