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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604123
Report Date: 05/13/2022
Date Signed: 05/24/2022 01:40:05 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
11/01/2021 and conducted by Evaluator Sabel Martinez
COMPLAINT CONTROL NUMBER: 08-AS-20211101084721
FACILITY NAME:MERAKEY - WYNDEMEREFACILITY NUMBER:
374604123
ADMINISTRATOR:ANN MARIE STANTONFACILITY TYPE:
737
ADDRESS:26184 WYNDEMERE CTTELEPHONE:
(267) 326-7436
CITY:ESCONDIDOSTATE: CAZIP CODE:
92026
CAPACITY:4CENSUS: 4DATE:
05/13/2022
UNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Administrator, Ann Marie StantonTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff did not follow resident's emergency interventation plan.
Licensee did not meet reporting requirements.
INVESTIGATION FINDINGS:
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This is an amended report. Correct visit date is 5/18/22.
Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced complaint visit to conduct interviews, and deliver findings regarding the above-mentioned allegations. The LPA was greeted by Administrator, Ann Marie Stanton, identified himself, and disclosed the purpose of the visit.

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

It was alleged the staff did not follow resident's emergency intervention plan. A review of Resident # 1’s (R1) Emergency Response Plan (ERP) revealed a history of aggression towards others, verbal threats, social inappropriateness, and unsubstantiated allegations. A review of R1’s Safety Net Crisis Plan (SNCP), a component to R1’s Emergency Intervention Plan, defined physical aggression as pushing, kicking, hitting, throwing/ breaking items, and slamming doors.
(See LIC 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022
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-20211101084721
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: MERAKEY - WYNDEMERE
FACILITY NUMBER: 374604123
VISIT DATE: 05/13/2022
NARRATIVE
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This is an amended report. Correct visit date 5/18/2022.

When R1 becomes physically aggressive with staff, the SNCP indicates staff will evade and use the least restrictive Crisis Prevention Intervention (CPI) method to assist R1. Multiple interviews with staff revealed some of the techniques used during this incident did not reflect CPI interventions, descriptions of the intervention as a single person hold, and resembling MMA (Mixed Martial Arts) techniques. Staff interviews, and a review of records confirmed the facility has conducted an incident debriefing, and staff have been retrained in CPI methods.

It was alleged the licensee did not meet reporting requirements. An interview with an outside source confirmed an external review of the incident, including the debriefing process, was conducted, and revealed the facility did not meet reporting requirements. Review of the incident debriefing documents and an interview with staff confirmed the reporting requirements were not met.

Based on review of records and interviews, there is a preponderance of evidence to prove the alleged violations occurred, therefore, the allegations are Substantiated. These deficiencies are documented in an LIC 9099D

An exit interview was conducted with Administrator, Ann Marie Stanton, to whom a copy of this report and Licensee's Rights (LIC 9058 01/16) were provided to.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20211101084721
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: MERAKEY - WYNDEMERE
FACILITY NUMBER: 374604123
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/19/2022
Section Cited
CCR
85102(a)(8)
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85102 Emergency Intervention Prohibitions. (a) The following emergency interventions shall not be used on a client: (8) Any manual restraint technique in which a staff member places pressure on a person's back or places his or her body weight against the person's torso or back; This requirement is not met as evidenced by:
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Administrator confirmed all staff at the facility were re-trained in Crisis Prevention Intervention (CPI) Methods, whitin this year. Administrator will provide the LPA documentation confirming all staff were re-trained in CPI, by 5/19/2022. POC will be cleared on 5/19/2022.
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Based on interviews, and records reviews, staff used an emergency intervention restraint technique that is prohibited in 1 of 3 persons in care which posed an immediate health, safety, and personal rights risk to persons in care.
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Type A
05/19/2022
Section Cited
CCR
80061(c)
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80061 Reporting Requirements. (c) Any
suspected physical abuse that does not result in serious bodily...dependent adult shall be reported to the... corresponding licensing agency...as required by Welfare and Institutions Code Section 15630(b)(1). This requirement is not met as evidenced by::
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Administrator confirmed all staff were re-trained in mandated reporting requirements, on 4/11/2022. POC will be cleared on 5/19/2022.
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Based on records review, and interviews, the Licensee did not meet reporting requirements which posed an immediate health, safety, and personal rights risks to 3 persons in care.
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Administrator will submit training log including topics discussed and attendees, by 5/19/2022.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3