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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604267
Report Date: 01/25/2023
Date Signed: 01/25/2023 12:59:05 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, 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
12/16/2021 and conducted by Evaluator Dang Nguyen
COMPLAINT CONTROL NUMBER: 08-AS-20211216150024
FACILITY NAME:CLOISTERS OF THE VALLEY, LLCFACILITY NUMBER:
374604267
ADMINISTRATOR:KELLY, CHANNAFACILITY TYPE:
740
ADDRESS:4171 CAMINO DEL RIO SOUTHTELEPHONE:
(619) 283-2226
CITY:SAN DIEGOSTATE: CAZIP CODE:
92108
CAPACITY:70CENSUS: 63DATE:
01/25/2023
UNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Business Office Director Susan DizonTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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-Licensee did not ensure a resident received personal care.
-Licensee restricted resident’s right to receive visitors.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced subsequent visit to deliver findings regarding the above prior complaint allegations. LPA was welcomed by and identified himself to Receptionist Rebecca Lane. LPA then met with and discussed the purpose of the visit with Business Office Director Susan Dizon.

It was alleged licensee did not provide Resident #1 (R1) needed personal care because on multiple occasions R1 was observed with unclean hair or wearing the same clothes over consecutive days. It was also alleged licensee restricted R1's right to receive visitors. CCLD’s investigation involved multiple unannounced facility tours/welfare checks and interviews of pertinent facility staff and outside sources. Relevant care and administrative records, hospice records, outside records, and digital images/videos were also reviewed.

[CONTINUED ON LIC 9099-C, 1 of 3]
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023
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 8
Control Number 08-AS-20211216150024
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: CLOISTERS OF THE VALLEY, LLC
FACILITY NUMBER: 374604267
VISIT DATE: 01/25/2023
NARRATIVE
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[CONTINUED FROM LIC 9099]

Due to their baseline disorientation, memory loss, and language impairment, R1 was not able to participate as a reliable historian/interviewee in this investigation. According to R1’s LIC602 Physician’s Report, R1 was diagnosed with Alzheimer’s type dementia, deemed non-ambulatory, and required help with bathing and dressing tasks. R1’s Care/Service Plan confirmed they needed assistance with bathing and dressing. R1’s Pre-Admission Resident Assessment reiterated these points and further specified R1 was to be bathed “2 times per week.”

According to R1’s hospice agency records, a hospice aide/caregiver typically visited R1 at the facility twice per week, spaced a few days apart, to help R1 with bathing. However, there were two notable exceptions during the short period R1 lived at Cloisters: a) during November 2021, there was a span of six consecutive days that the hospice aide did not visit; b) during December 2021, there was a span of seven consecutive days that the hospice aide did not visit.

Per interviews of facility managers Staff #1 (S1), Staff #2 (S2), and 15 direct-care staff: all residents of the facility were to be bathed at least twice per week, except that for residents on hospice care their bath/shower was usually rendered by a visiting hospice aide. CCLD asked staff how hospice residents’ bathing needs were met during occasions when hospice aide(s) failed to visit the facility: 9 of the 15 direct care staff said Cloisters staff never completed baths/showers missed by hospice aides. Another 2 said they reassigned missed baths/showers to Cloisters coworkers, but these were infrequently completed due to licensee not staffing enough caregivers to meet residents’ needs. Another 2 claimed they completed baths/showers missed by hospice, but when asked for examples of hospice residents they bathed or saw coworkers bathe, could not name any. The last 2 were able to name at least one hospice resident who received a make-up bath/shower from Cloisters staff, but one of these staff also said more than 50% of all the showers due, to include non-hospice residents, were not actually delivered by the Cloisters team due too few caregivers on duty.

[CONTINUED ON LIC 9099-C, 2 of 3]
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 08-AS-20211216150024
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: CLOISTERS OF THE VALLEY, LLC
FACILITY NUMBER: 374604267
VISIT DATE: 01/25/2023
NARRATIVE
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[CONTINUED FROM LIC 9099-C, 1 of 3]

S1, S2, and all 15 direct care staff interviewed said residents who required help with dressing were to receive it at least twice per day from Cloisters caregivers: once in the AM shift after waking up, once on the PM shift before going to bed, and as needed if clothes became soiled. R1 was no different in this respect. In interviews, 9 of the 15 direct-care staff remembered R1 well enough to comment on their clothes. 4 said they witnessed multiple occasions where R1 wore the same clothes over stretches of 2 to 3 days, which they attributed to being short-staffed or coworkers not being supervised. Another 2 did not comment specifically on R1’s clothing but said caregiver shortages contributed to many residents not having their clothes changed daily.

Licensee’s staff used Software #1 to electronically record the care tasks they provided to residents. “Bathing” and/or “Showering” tasks were never tracked for R1. The closest approximation which staff charted on was “Personal Hygiene,” vaguely defined in the report as, “Requires assistance for personal hygiene.” However, given that R1 also required help with bathroom use, staff’s charting on “Personal Hygiene” did not offer reliable insight into whether, or when, R1 received baths/showers. The frequency at which Cloisters staff documented providing “Personal Hygiene” to R1 also did not correlate with R1’s twice-weekly bathing need. Software #1 showed Cloisters staff did chart they provided R1’s “Dressing” assistance on most AM and PM shifts, but there were also 13 shifts that had blank/missing entries (with no comments indicating if R1 was offered dressing help but refused it). For 19 of the days during which R1 lived at Cloisters, CCLD obtained and reviewed date and time-stamped screenshots (and some recordings) of R1 participating in Zoom video calls with outside persons. Screenshots showed four separate occasions when R1 wore the same shirt 2 days in a row and one occasion when R1 wore the same shirt 4 days in a row.

Per Title 22 of the California Code of Regulations, all RCFE residents are entitled “to have their visitors…permitted to visit privately during reasonable hours and without prior notice." Throughout the time R1 lived at the facility, California was under a State of Emergency due to the COVID-19 pandemic (Governor’s Executive Order N-12-21). A CDSS-approved statewide waiver, as was then described in Provider Information Notice (PIN) 21-40-ASC, amended certain but not all aspects of the residents’ visitation right. [CONTINUED ON LIC 9099-C, 3 of 3]
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 08-AS-20211216150024
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: CLOISTERS OF THE VALLEY, LLC
FACILITY NUMBER: 374604267
VISIT DATE: 01/25/2023
NARRATIVE
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[CONTINUED FROM LIC 9099-C, 2 of 3] The PIN required licensees to verify that each indoor visitor was either fully vaccinated (or possessed a recent negative test result), asymptomatic, wore a face mask, performed hand hygiene, and socially distanced from others. It recommended such “Best Practices” as: a) “Limit the number of visitors on the facility premises at any one time to avoid having large groups congregate (based on the size of the building and physical space).”; b) “Limit visitor movement in the facility…visitors should not walk around different halls…”; c) “Encourage shorter indoor visits and longer outdoor visits,” d) “Record name and contact information for individuals entering… for possible contact tracing…,” and e) “Clean and disinfect frequently touched surfaces…often and…after each visit.”

According to interviews of S1, S2, and outside sources: during the timeframe of the complaint allegation, licensee required non-essential visitors to use Software #2 to make a reservation before having an indoor, outdoor, or virtual visit (which occurred via Zoom on the facility’s tablet device). Visitors self-selected either 30-minute (indoor and virtual) or 45-minute (outdoor) visit slots, which were not per resident, but per facility. By the commencement of CCLD’ investigation, licensee’s census had settled at 58 residents in care. This meant that while 1 resident was receiving their non-essential visitor, 57 other residents could not. Interviews also revealed that for any unclaimed visit slots that fell within 24 hours of the visit time, Software #2 automatically removed them (they disappeared) as selectable options for potential visitors. Residents were thus categorically denied the ability to receive a non-essential visitor on short notice. PIN 21-40-ASC did not numerically define a “congregation,” but it instructed licensees to consider the “size of the building and physical space.” CDSS’ statewide waiver did not waive residents’ right to receive visitors “without prior notice.”

Based on interviews and records reviewed, a preponderance of evidence exists to show that licensee did not meet R1’s personal care needs, and that licensee restricted residents’ visitation rights beyond what was authorized in CDSS’ COVID-19 statewide waiver. Both allegations are therefore substantiated. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Dizon, to whom a copy of this report, the LIC 9099-D, and the Licensee/Appeal Rights (LIC9058 01/16) were provided.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023
LIC9099 (FAS) - (06/04)
Page: 8 of 8
Control Number 08-AS-20211216150024
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: CLOISTERS OF THE VALLEY, LLC
FACILITY NUMBER: 374604267
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/23/2023
Section Cited
CCR
87411(a)
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87411 Personnel Requirements – General: “(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.” This requirement was not met, as evidenced by:
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Licensee agreed to increase and maintain the total number of caregivers it staffs every day, such that the resident to caregiver ratio during AM and PM shifts will not exceed 16 residents per caregiver. Licensee agreed to implement this scheduling change by 02/23/2023. Licensee agreed to E-mail LPA updated a copy of the monthly caregiver work schedule and roster of active residents, by the POC due date.
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Based on interviews and records reviewed, the licensee did not employ personnel in sufficient numbers to meet the personal care needs of 1 of 58 residents (R1) in care, which poses a potential health risk to persons in care.
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Type B
02/23/2023
Section Cited
CCR
87468.1(a)(10)
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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: (10) To have their visitors…permitted to visit privately during reasonable hours and without prior notice…”
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As of the date issuance for this deficiency, Licensee said Software #2 is no longer in use at the facility and non-essential visitors are no longer required to make reservations to visit. The resolves the deficiency.
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This requirement was not met, as evidenced by: Based on interviews and records reviewed, the licensee did not allow a resident to receive their visitor without prior notice for 1 of 58 residents (R1) in care, which poses a potential personal rights risk to persons 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: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 8
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
12/16/2021 and conducted by Evaluator Dang Nguyen
COMPLAINT CONTROL NUMBER: 08-AS-20211216150024

FACILITY NAME:CLOISTERS OF THE VALLEY, LLCFACILITY NUMBER:
374604267
ADMINISTRATOR:KELLY, CHANNAFACILITY TYPE:
740
ADDRESS:4171 CAMINO DEL RIO SOUTHTELEPHONE:
(619) 283-2226
CITY:SAN DIEGOSTATE: CAZIP CODE:
92108
CAPACITY:70CENSUS: 63DATE:
01/25/2023
UNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Business Office Director Susan DizonTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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-Licensee did not report a resident’s change in condition health, as required.
-Licensee did not provide required variety of activities to residents with dementia.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced subsequent visit to deliver findings regarding the above prior complaint allegations. LPA was welcomed by and identified himself to Receptionist Rebecca Lane. LPA then met with and discussed the purpose of the visit with Business Office Director Susan Dizon.

The complainant alleged that Resident #1 (R1) developed a pronounced cold/cough around 12-14-2021 and licensee did not report this to R1’s responsible party and hospice provider, as required. It was also alleged that licensee did not offer activities meeting the needs of residents diagnosed with dementia. CCLD’s investigation involved multiple unannounced facility tours/welfare checks and interviews of pertinent facility staff and outside sources. Relevant care and hospice records, activity calendars, vendor invoices, photos, and video footage were also reviewed.

[CONTINUED ON LIC 9099-C, 1 of 2]
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 08-AS-20211216150024
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: CLOISTERS OF THE VALLEY, LLC
FACILITY NUMBER: 374604267
VISIT DATE: 01/25/2023
NARRATIVE
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[CONTINUED FROM LIC 9099]

Per their LIC602 Physician’s Report, R1 was diagnosed with Alzheimer’s type dementia. Due to their baseline disorientation, memory loss, and language impairment, R1 was not able to participate as a reliable historian/interviewee in this investigation. However, CCLD reviewed recorded footage of a Zoom video call R1 participated in on 12-13-2021: throughout the nearly 9-minute recording, R1 did not cough, sneeze, or display cold symptoms. In interviews, managers Staff #1 (S1), Staff #2 (S2), and 8 of 9 direct care staff said they did not see R1 display any sign of cough/cold on either 12-13-2021 or 12-14-2021. One staff said R1 had “a little cough” around this time but described it as “not a serious one.” CCLD also interviewed 4 outside persons who visited R1 on either 12-13-2021, 12-14-2021, or both days, either in person or virtually: they gave conflicting accounts as to when R1’s cough started, but most agreed it was not noticeable until 12-14-2021 or later.

Cloisters’ progress notes did not mention R1 having any cold symptoms on 12-14-2021, or in the days leading up. Per the hospice agency’s progress notes, R1 was first identified to have a cough/cold on 12-15-2021, after they had moved out of Cloisters of the Valley, LLC and relocated to their new home, Residence #2. R1’s responsible party and hospice team treated the cold and R1 made a full recovery a few days later.

CCLD reviewed the facility’s activity calendar from the timeframe of the allegation; it contained examples of each of the required activity categories described in regulation 87219 Planned Activities (i.e. Socialization, Daily Living Skills/Activities, Leisure Time, Physical, Educational, Free Time, and Community-Centered). The calendar and a vendor’s invoice showed proof “large motor activities” and the facility’s activity cart contained supplies for “perceptual and sensory stimulation,” satisfying portions of regulation 87705 Care of Persons with Dementia pertaining to activities.

Per interviews of 15 of 15 direct care staff, activities in practice usually followed the posted calendar. Staff said during the timeframe of the allegation, licensee employed a full-time activities director who was aided by two assistants. During 3 of 3 unannounced visits, LPA observed staff leading an activity with residents, which also occurred at the time specified in the posted calendar. 2 of the 3 activities which LPA observed were also accessible to residents diagnosed with dementia. [CONTINUED ON LIC 9099-C, 2 of 2]
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 08-AS-20211216150024
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: CLOISTERS OF THE VALLEY, LLC
FACILITY NUMBER: 374604267
VISIT DATE: 01/25/2023
NARRATIVE
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[CONTINUED FROM LIC 9099-C, 1 of 2]

Based on interviews and records, there does not exist a preponderance of evidence showing R1’s cough reached the level of a reportable change in physical condition while under licensee’s care. There also does not exist a preponderance of evidence showing licensee’s activity program did not meet the variety minimums described in regulations. Both allegations are therefore unsubstantiated. An exit interview was conducted with Dizon, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 8