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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604200
Report Date: 08/21/2024
Date Signed: 08/21/2024 05:38:50 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
02/02/2021 and conducted by Evaluator Tiffany Holmes
COMPLAINT CONTROL NUMBER: 08-AS-20210202142341
FACILITY NAME:NEW WORLD RCFEFACILITY NUMBER:
374604200
ADMINISTRATOR:MELTON, JEANFACILITY TYPE:
740
ADDRESS:14125 TARZANA ROADTELEPHONE:
(858) 842-4608
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY:6CENSUS: 6DATE:
08/21/2024
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Nirissa Imperial, CaregiverTIME COMPLETED:
10:50 AM
ALLEGATION(S):
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9
Staff inappropriately restrained resident.
Staff failed to meet the resident's needs.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA)Tiffany Holmes conducted an unannounced complaint visit to the facility to deliver findings on the above-mentioned allegations. LPA gained access to the facility, identified herself, and met with Nirissa Imperial, Caregiver to discuss the purpose of the visit.

LPA conducted the initial investigation visit on February 12, 2021, and was able to interview clients, facility staff, and outside sources. LPA also reviewed records and conducted a physical inspection of the facility. It was alleged that staff inappropriately restrained resident. Interviews revealed with outside sources revealed Resident 1 (R1) was in a wheel chair restrained with a gait belt so they wouldnt fall out. Other interviews revealed that the resident was restrained by a caregiver and the caregiver was reprimanded for the action.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Tiffany HolmesTELEPHONE: (619) 481-0843
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
02/02/2021 and conducted by Evaluator Tiffany Holmes
COMPLAINT CONTROL NUMBER: 08-AS-20210202142341

FACILITY NAME:NEW WORLD RCFEFACILITY NUMBER:
374604200
ADMINISTRATOR:MELTON, JEANFACILITY TYPE:
740
ADDRESS:14125 TARZANA ROADTELEPHONE:
(858) 842-4608
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY:6CENSUS: 6DATE:
08/21/2024
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Nirissa Imperial, CaregiverTIME COMPLETED:
10:50 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not ensure resident was adequately hydrated resulting in hospitalization.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA)Tiffany Holmes conducted an unannounced complaint visit to the facility to deliver findings on the above-mentioned allegations. LPA gained access to the facility, identified herself, and met with Nirissa Imperial, Caregiver to discuss the purpose of the visit.

LPA conducted the initial investigation visit on February 12, 2021, and was able to interview clients, facility staff, and outside sources. LPA also reviewed records and conducted a physical inspection of the facility. It was alleged that Staff did not ensure resident was adequately hydrated resulting in hospitalization. Interviews revealed

The investigation did not produce supporting evidence or supporting witness statements to substantiate Staff did not ensure resident was adequately hydrated resulting in hospitalization. Based on the evidence obtained from interviews, and record review, the complaint allegation is unsubstantiated.

An exit interview was conducted with Nirissa Imperial, Caregiver and a copy of this report along with Licensee/Appeal Rights (LIC 9058 03/22) was provided at the conclusion of the visit.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Tiffany HolmesTELEPHONE: (619) 481-0843
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 08-AS-20210202142341
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: NEW WORLD RCFE
FACILITY NUMBER: 374604200
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/06/2024
Section Cited
CCR
87468.1(a)(1)
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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:
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Facility staff will be trained on Residents Rights/Personal rights by an outside source. Training and documents willbe due to CCL by POC date of 09/06/02024
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Interviews revealed that R1 was restrained to their wheelchair by a gait belt by staff. This posed an immediate safety risk to the 1 out of 6 (R1)residents in care.
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Type B
08/30/2024
Section Cited
CCR
87307(a)(3)(F)
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Personal Accommodations and Services. The following provisions shall apply: The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: Basic laundry service. This requirement was not met as evidenced by:
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Licensee will provide training on how to properly load and unload the washer and the dryer to all staff. POC due by 08/30/2024. Statement that training was completed will be sent to LPA Holmes by 08/30/2024
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Interviews revealed that laundry was not being washed for 2-3 weeks. This poses a potential health risk to the 6 of 6 (R1) residents in care.
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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: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Tiffany HolmesTELEPHONE: (619) 481-0843
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 08-AS-20210202142341
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: NEW WORLD RCFE
FACILITY NUMBER: 374604200
VISIT DATE: 08/21/2024
NARRATIVE
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 It was alleged that staff failed to meet the resident's needs. Interviews revealed that the facility's washer machine was not working due to the staff overcrowding the machine with clothes. Interviews revealed that they called to have the machine worked on to be repaired and the machines were down for 2-3 weeks before they were fixed. Interviews revealed the once they realized the washer was not working they would take the clothes to the sister facilities 2-3 times a week to do the laundry. Interviews revealed during the time period, there may have been times when some clothes were not being washed.

The investigation produced supporting witness statements to substantiate staff inappropriately restrained resident and staff failed to meet the resident's needs. Based on the evidence obtained from interviews the complaint allegations are substantiated.

An exit interview was conducted with Nirissa Imperial, Caregiver and a copy of this report along with Licensee/Appeal Rights (LIC 9058 03/22) was provided at the conclusion of the visit.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Tiffany HolmesTELEPHONE: (619) 481-0843
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4