374604267-1-25-2023-08-AS-IESA-CNM3YS-20230131174024

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604267
Report Date: 10/17/2022
Date Signed: 01/25/2023 10:56:08 AM

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
10/20/2021 and conducted by Evaluator Dang Nguyen

COMPLAINT CONTROL NUMBER: 08-AS-20211020144334

FACILITY NAME:	CLOISTERS OF THE VALLEY, LLC		FACILITY NUMBER:	374604267
ADMINISTRATOR:	KELLY, CHANNA		FACILITY TYPE:	740
ADDRESS:	4171 CAMINO DEL RIO SOUTH		TELEPHONE:	(619) 283-2226
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92108
CAPACITY:	70	CENSUS: 62	DATE:	10/17/2022
		UNANNOUNCED	TIME BEGAN:	01:35 PM
MET WITH:	Receptionist Rebecca Lane & Interim Executive Director Emily DeLaBarre		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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-Licensee unlawfully evicted resident.
-Licensee denied resident access to their medical records.

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, identified himself to, and discussed the purpose of the visit with Receptionist Rebecca Lane. Interim Executive Director Emily DeLaBarre later joined the visit via phone call.

It was alleged Resident #1 (R1) moved out of the facility because manager Staff #1 (S1) pressured them to, despite licensee not issuing R1 a written 30-day notice to vacate. It was also alleged that R1 requested but S1 withheld, copies of notes from R1’s primary physician and contact information for R1’s outside social worker. CCLD’s investigation involved multiple unannounced facility tours, interview of R1 and pertinent facility staff, and review of facility progress notes and written correspondence.

[CONTINUED ON LIC 812-C, 1 of 2]

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2022

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-20211020144334

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: 10/17/2022

NARRATIVE

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[CONTINUED FROM LIC 9099]

All interviews showed R1 was their own responsible party and their stay at the facility was subsidized by a third-party payee, a Medi-Cal based health group (HG). (The facility itself was not a direct recipient of Medi-Cal or Supplemental Security Income funds.) Based on a recent reassessment, R1’s physician determined that R1 could now self-manage their medications. R1 no longer met criteria for continued HG funding, and it expired. Around this time, R1 had multiple conversations with S1 in person and through written correspondence. According to Staff #2 (S2), they were witness to at least one of these in-person meetings. Per S1’s interview: they did not ask R1 to relocate from the facility. Rather, they invited R1 to continue living at the facility under their existing residency agreement contract and pay privately. However, R1 did not want to be indebted to the facility and elected to leave, choosing their own move out date, and arranging the logistics of their departure. In their interview, S2 corroborated that S1 did not ask R1 to move out; R1 voluntarily left.

CCLD reviewed the facility’s time and date stamped electronic progress notes, which said R1 was “independent with all ADLs” and “able to make [their] own decisions,” described the move out arrangements R1 made for themselves, and reiterated that “[R1] voluntarily discharged” because “insurance stopped coverage for assisted living and [R1 was] unable or unwilling to pay private pay for room and board.” CCLD also reviewed written correspondence between R1 and facility staff, which confirmed they were not being evicted and the move-out was their choice.

There was no evidence in staff interviews, facility progress notes, or written correspondence to corroborate that R1 requested care documents beyond their facility medication list. S1 and S2 said on move out day, R1 left the facility with both their medication list and active medications, which the facility’s progress notes and R1 themselves confirmed. Regarding R1’s desire to contact their HG social worker, S1 told CCLD they provided R1 with the HG’s main phone number, as per the HG’s protocol. In their interview, R1 confirmed knowing their HG member identification number, calling the HG at the number S1 provided, and speaking directly with their HG physician multiple times. In a subsequent interview: R1 told CCLD they appealed the HG’s decision to end their assisted living subsidy and won. R1 found new housing and did not seek to return to Cloisters of the Valley, LLC.

[CONTINUED ON LIC 9099-C, 2 of 2]

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 08-AS-20211020144334

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: 10/17/2022

NARRATIVE

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[CONTINUED FROM LIC 9099-C, 1 of 2]

Based on interviews and records, a preponderance of evidence does not exist to prove that licensee evicted R1 unlawfully, or that licensee denied R1 access to their medical records or payee. Both allegations are therefore unsubstantiated. An exit interview was conducted with DeLaBarre and Lane, to whom copies of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2022

LIC9099 (FAS) - (06/04)

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