374604260-4-20-2023-18-AS-RSTS-D3RMF3-20240327093336

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604260
Report Date: 04/20/2023
Date Signed: 04/20/2023 03:29:14 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/14/2023 and conducted by Evaluator Stephanie Torres

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20230414080625

FACILITY NAME:	WEAVER'S TWIN OAKS VILLA		FACILITY NUMBER:	374604260
ADMINISTRATOR:	WEAVER, TONYA		FACILITY TYPE:	740
ADDRESS:	2115 TWIN OAKS VALLEY ROAD		TELEPHONE:	(760) 798-4141
CITY:	SAN MARCOS	STATE: CA	ZIP CODE:	92069
CAPACITY:	6	CENSUS: 5	DATE:	04/20/2023
		UNANNOUNCED	TIME BEGAN:	11:50 AM
MET WITH:	Babett Gardner, Assistant Administrator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Resident sustained pressure injury while in care
Staff did not follow resident's care plan

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to start the investigation into the above allegations. The LPA met with Babette Gardner, Assistant Administrator, and informed her of the purpose of her visit.

The investigation included staff interviews, records review, and record collection of relevant documentation.

Regarding the allegation, "Resident sustained pressure injury while in care," it was alleged Resident One (R1) developed a sore and other injuries due to not being repositioned regularly. A Physician's Report for Residential Care Facilities for the Elderly (RCFE) revealed R1 had a motor impairment/paralysis and was considered non-ambulatory. Staff reported R1 did require assistance to reposition and the assistance was provided throughout the day. Staff interviews revealed R1 did develop discoloration to their buttock around March 07, 2023. An interview could not be conducted with R1 due to the resident passing away on March 07, 2023. Therefore, due to insufficient information, this allegation is deemed UNSUBSTANTIATED at this time.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023

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 18-AS-20230414080625

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: WEAVER'S TWIN OAKS VILLA	FACILITY NUMBER: 374604260
	VISIT DATE: 04/20/2023

NARRATIVE

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Regarding the allegation, "Staff did not follow resident's care plan," it was alleged facility staff would no longer provide R1 with bathes three times a week, nor would they change the resident daily, as their health began to declined. The Admission Agreement on file revealed bathes would be provided to residents three times each week. Staff interviews revealed R1 was provided bathes two times a week, by a third party healthcare provider, while facility staff provided sponge bathing once a week. In addition, staff reported to have changed R1 daily. Interview with a third party provider revealed no concerns were observed relating to the care provided to R1 be the facility. An interview could not be conducted with R1 due to the resident passing away on March 07, 2023. Therefore, due to insufficient information, this allegation is deemed UNSUBSTANTIATED at this time.

A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

This report was reviewed with Gardner and a copy was provided.

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023

LIC9099 (FAS) - (06/04)

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