374604115-7-26-2022-08-AS-LTEZ-CGRPS9-20220728113355

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604115
Report Date: 07/26/2022
Date Signed: 07/26/2022 04:56:27 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,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/07/2021 and conducted by Evaluator Sabel Martinez

COMPLAINT CONTROL NUMBER: 08-AS-20211207090521

FACILITY NAME:	COUNTRY ROSE ESTATE MEMORY CARE		FACILITY NUMBER:	374604115
ADMINISTRATOR:	PARAISO, CATHERINE T		FACILITY TYPE:	740
ADDRESS:	1255 ADVENTURE LN		TELEPHONE:	(760) 738-9391
CITY:	SAN MARCOS	STATE: CA	ZIP CODE:	92069
CAPACITY:	15	CENSUS:	DATE:	07/26/2022
		UNANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	Yuri Ramirez Olvera		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff do not treat client with dignity.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA), Sabel Martinez, completed an unannounced complaint visit to conduct additional interviews and deliver findings regarding the mentioned allegation. The LPA was greeted by Caregiver. Yuri Ramirez Olvera, identified himself, and disclosed the purpose of the visit.

Throughout the investigation, the LPA toured the facility, reviewed staff records, resident records, and conducted interviews with residents, staff, and outside sources.

It was alleged staff did not treat a resident with dignity. Interviews with staff and residents revealed that on at least one occasion, Staff #1 (S1) was witnessed to be irritated and raising their voice at residents in care. Staff # 2 (S2) was described as argumentative and raising their voice at residents. Licensee was provided with Confidential Names Form, in order to identify S1 and S2. Interviews with residents corroborated perceiving that facility staff did not treat residents with dignity and staff were described as being “feisty” and "mean" with residents.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 380-3797
LICENSING EVALUATOR NAME: Sabel Martinez	TELEPHONE: (619) 755-7595
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022

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 3

Control Number 08-AS-20211207090521

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: COUNTRY ROSE ESTATE MEMORY CARE	FACILITY NUMBER: 374604115
	VISIT DATE: 07/26/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Based on the evidence gathered, there is a preponderance of evidence to prove the alleged violation occurred, therefore, the allegation is Substantiated. This deficiency is documented on an LIC 9099D, and is cited in accordance with California Code of Regulations, Title 22.

Administrator, Val Paraiso, was called, notified of the findings, and jointly formulated a Plan of Correction.

An exit interview was conducted with Caregiver, Yuri Ramirez Olvera, to whom a copy of this report and Licensee's Rights (LIC 9058 01/16) were provided to.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 380-3797
LICENSING EVALUATOR NAME: Sabel Martinez	TELEPHONE: (619) 755-7595
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 08-AS-20211207090521

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: COUNTRY ROSE ESTATE MEMORY CARE	FACILITY NUMBER: 374604115
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/26/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/26/2022 Section Cited CCR 87468.1(a)(1)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by	1 2 3 4 5 6 7	Administrator agreed to conduct in service training for all staff regarding Personal Rights of Residents in All facilities. Attendance sheet for this training will be submitted to the LPA by 8/26/2022.
	8 9 10 11 12 13 14	Based on interviews, the Licensee did not ensure residents in care were treated with dignity which posed a potential health, safety, and Personal Rights risk to 3 of 14 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) 380-3797
LICENSING EVALUATOR NAME: Sabel Martinez	TELEPHONE: (619) 755-7595
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3