374604149-12-28-2022-08-AS-SJAB-CMLMF4-20221230083343

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604149
Report Date: 12/28/2022
Date Signed: 12/28/2022 02:28:24 PM

Unsubstantiated

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
03/02/2022 and conducted by Evaluator Esther Miller

PUBLIC

COMPLAINT CONTROL NUMBER: 08-AS-20220302142646

FACILITY NAME:	NORTH COUNTY CARE HOME		FACILITY NUMBER:	374604149
ADMINISTRATOR:	CAMPAS, CARMEN		FACILITY TYPE:	740
ADDRESS:	15042 AMSO ST		TELEPHONE:	(858) 842-4608
CITY:	POWAY	STATE: CA	ZIP CODE:	92064
CAPACITY:	6	CENSUS: 6	DATE:	12/28/2022
		UNANNOUNCED	TIME BEGAN:	12:36 PM
MET WITH:	Carmen Campas, Administrator		TIME COMPLETED:	01:36 PM

ALLEGATION(S):

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Resident is not being accorded privacy during visitation.
Resident is not receiving adequate meal service.
Staff do not properly clean resident's dentures.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Esther Miller conducted an unannounced complaint investigation visit to the facility in order to deliver findings on the above allegations. LPA was granted entry to the facility by Carla Carachure, caregiver, after identifying herself and explaining the reason for the visit. Carmen Campas, Administrator, arrived later during the visit.

On December 13, 2021, it was alleged that resident was not being accorded privacy during visitation, resident was not receiving adequate meal service, and staff did not properly clean resident’s dentures. The Department’s investigation consisted of review of observations, facility records, and interviews of facility staff and outside sources.

Facility records indicated that resident 1 (R1) was admitted to the facility and hospice on January 13, 2022 and was provided medical services. Staff interviews revealed that they noticed medical services

[Continued on LIC9099-C, Page 1 of 3]

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther Miller	TELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2022

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 3

Control Number 08-AS-20220302142646

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: NORTH COUNTY CARE HOME	FACILITY NUMBER: 374604149
	VISIT DATE: 12/28/2022

NARRATIVE

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rendered to R1 after a visit from a nonmedical person. Administrator stated that R1’s visitor admitted to her that they were providing medical care while visiting R1 with the doors closed. Administrator provided clarification to R1’s visitor that they could not provide medical services. Interview with medical professionals revealed they had also told R1’s visitor that they could not provide medical services to R1 around the time R1 was admitted to the facility. Facility records revealed a communication log from hospice that indicated R1’s visitor had admitted to providing medical care prior to hospice’s arrival on February 15, 2022. Interview with hospice nurse who wrote the note was attempted but not realized. Staff interviews revealed they witnessed evidence of medical care being provided to R1 despite hospice not visiting and always after R1’s visitor left. R1’s Power of Attorney stated that R1’s visitor admitted to them that R1’s visitor was visiting as often as possible to provide medical services to R1. On February 25, 2022, the Department received an email from the Administrator which admitted to not allowing R1’s visitor to visit with the door closed because they did not want R1’s visitor to provide medical services. On March 2, 2022, a medical doctor that was assessing R1 to become a patient admitted in an email to Administrator that they observed R1’s visitor provided medical services. The allegation that resident was not accorded privacy during visitation is found to be UNSUBSTANTIATED, meaning that there is not a preponderance of the evidence to prove that the alleged violation occurred.

It was also alleged that the facility did not provide adequate meal service. Facility records indicated that from February 25, 2022 to March 8, 2022, R1 did eat most of their food every day. Medical professionals that cared for R1 and staff interviews indicated that R1 ate well. Staff interviews and facility records showed that R1 was on a mechanical soft diet which allowed R1 to eat with or without dentures in place. Facility records and outside source interviews indicated that R1 moved out of the facility on March 12, 2022 to another licensed facility. Administrator stated that R1 ate well while at the new facility and did not feel that R1 arrived malnourished. The allegation that the facility did not provide adequate meal service is found to be UNSUBSTANTIATED, meaning that there is not a preponderance of the evidence to prove that the alleged violation occurred.

It was also alleged that staff did not properly clean resident's dentures. Outside source provided photos of R1’s dirty denture. The photo was taken on March 1, 2022 at 4:43PM. The photo showed the dentures with black and white debris around the teeth. There were no other photos of R1’s dentures, dirty or otherwise.

[Continued on LIC9099-C, Page 2 of 3]

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther Miller	TELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 08-AS-20220302142646

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: NORTH COUNTY CARE HOME	FACILITY NUMBER: 374604149
	VISIT DATE: 12/28/2022

NARRATIVE

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[Continued from LIC9099-C, Page 3 of 3]

No other instances of dirty dentures were reported to LPA. Facility documents and staff interviews indicate that R1’s dentist came and trained staff on proper cleaning and insertion techniques. Dentist’s report did not indicate that dentures had debris on them or needed cleaning. Facility documentation indicated that staff documented dentures being cleaned. Staff interviews revealed staff’s knowledge of training provided and techniques to clean and insert dentures. Interviews with R1’s visitors did not reveal that they saw dentures with debris. Facility documentation and staff interviews revealed that R1 resisted having dentures inserted and did not wear them often. Interview with R1’s dentist was attempted but not realized.

An exit interview was conducted with Administrator; a copy of this report and Licensee's Rights (LIC9058) were provided.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther Miller	TELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2022

LIC9099 (FAS) - (06/04)

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