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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 12:45:41 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
07/14/2021 and conducted by Evaluator Dang Nguyen
COMPLAINT CONTROL NUMBER: 08-AS-20210714132834
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:
10:30 AM
MET WITH:Business Office Director Susan DizonTIME COMPLETED:
11:50 AM
ALLEGATION(S):
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-Facility staff did not give resident medication as prescribed.
-Facility staff did not treat resident with dignity.
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 facility staff did not give Resident #1 (R1) medication as prescribed, as illustrated by: a) staff “doubled” the Potassium Chloride and Bumex doses given to R1, leading to their hospitalization, and b) on other occasions, R1 entirely missed (staff did not give) prescribed doses. It was also alleged culinary Staff #1 (S1) did not treat R1 with dignity. CCLD’s investigation involved multiple unannounced facility tours/welfare checks, interviews of R1 and pertinent staff, and review of relevant facility care and administrative records.

[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 7
Control Number 08-AS-20210714132834
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’s primary diagnosis was “Mild Cognitive Impairment” and they needed help with “medication management.” In R1’s Pre-Admission Resident Appraisal, licensee wrote, “[R1] needs med management…” In R1’s Service Plan / Plan of Care, licensee wrote, “[R1] needs assistance with self-administration of medications,” “[R1] requires daily supervision of medication,” and “[R1] will be supported to take all medications safety as ordered.”

Hospital records showed R1 presented to an Emergency Department (ED) on 02-19-2021 complaining of shortness of breath, decreased urine output, and fluid retention in their belly and legs. Lab tests showed R1’s blood potassium on arrival was 7.0 mmol/L (versus the test’s normal reference range of 3.5 to 5.1 mmol/L). ED staff withheld R1’s Potassium Chloride medication, and by 02-25-2021 their measured blood potassium was back within normal range. Per hospital records, R1 told ED personnel: Cloisters’ staff “organizes the medication and they are administered according to the way they are prescribed…” and their medicine prescriptions “got messed up” when they moved into Cloisters. R1 told doctors they were prescribed twice the amount of Potassium Chloride, and half the amount of Bumex, that they wanted for themselves.

According to medical records, prior to R1’s 02-19-2021 hospitalization, they were prescribed: a) two 20 mEq tablets of Potassium Chloride, two times per day, and b) one 2 mg tablet of Bumex, two times per day. Upon discharge from the hospital on 02-25-2021, R1’s Potassium Chloride was stopped completely, and their Bumex order was kept the same as pre-admission. According to Cloisters’ Medication Administrator Records (MARs) for R1 during January 2021 and February 2021: leading up to R1’s 02-19-2021 hospital trip, staff gave R1 their Potassium Chloride and Bumex according to their respective prescriptions. Upon R1’s return to Cloisters, staff gave R1 their Bumex like before and halted their Potassium Chloride, consistent with the hospital’s discharge orders. Based on the evidence obtained, Licensee was not culpable for causing R1’s elevated potassium levels or hospitalization.

[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: 7 of 7
Control Number 08-AS-20210714132834
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]

CCLD reviewed MARs for five residents [R1, Resident #2 (R2), Resident #3 (R3), Resident #4 (R4), and Resident #5 (R5)], for the period from January 2021 through mid-July 2021. During this review period: R1 had 76 missed medicine doses (meaning they were not offered to R1). They involved nine different medicines and affected all months of the review period. Also, R2, R3, and R4 each had multiple missed doses of different medicines, affecting multiple months. Per staff notations on the MARs, some missed doses were due to staff awaiting delivery of medicines from the pharmacy, but there were also many missed doses with no comments/explanations provided..

CCLD interviewed 8 medication technicians and manager Staff #2 (S2), who provided general oversight to that team. S2 and 7 med techs said facility staff were responsible for obtaining R1’s medicine refills before they ran out, and while most residents’ medicines refilled automatically from licensee’s contracted pharmacy, staff also manually reordered medicines if they saw pills were running low. 5 med techs said they were required to contact the pharmacy for refill(s) if a resident had 6 to 7 days of pills remaining; S1 and other med techs said this was required 4 to 5 days before running out. 6 med techs said one of R1’s prescribed medicines frequently had its dose titrated/adjusted by R1’s physician. Sometimes the pharmacy could not dispense the medicine due to needing authorization/clarification from the doctor, resulting in delays, and missed doses. CCLD asked staff how they resolved these physician-authorization delays but received conflicting responses: some said they contacted R1’s physician who usually responded, some said they contacted R1’s physician who rarely responded, and some said Cloisters staff did not contact R1’s physician at all. CCLD asked the med techs if there were occasions residents missed doses, not due to authorization problems, but simply due to Cloisters staff being too slow to order medication refills: 4 med techs said missed doses due to late ordering occurred on multiple occasions.

In reference to the second allegation (regarding dignity), R1 told CCLD that they handed a paper to S1 showing their preferences for heart-healthy foods, but S1 crumpled it up in front of them and threw it away. R1 said they felt disrespected on other occasions too. In their interview, S1 denied having interpersonal conflict with R1, and confirmed receiving a list of heart-healthy food preferences from R1. S1 said they always followed this list, but when CCLD asked for examples of food adjustment they made to support R1 with this list, S1 could not name any.

[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: 3 of 7
Control Number 08-AS-20210714132834
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]

CDSS interviewed several non-managerial staff about the allegation: Staff #3 (S3) witnessed S1 ignore R1’s food request, then take steps to prevent other staff from meeting R1’s food request. S3 witnessed S1 speak to R1 using profanity. Staff #4 (S4) witnessed R1 request heart-healthy food but S1 rudely dismissed them. S4 witnessed S1 speak disrespectfully to other residents and staff too. Staff #5 (S5) said S1 did not honor residents’ food requests and was abrasive with R1, other residents, and other staff, to include public confrontations with managers. Staff #6 (S6) witnessed S1 slam pots and pans inside the kitchen in frustration, and said coworkers complained to them that S1 refused to accommodate residents’ food preferences. Staff #7 (S7) said S1 had a reputation for being rude. Employee records show S1 was formally disciplined/counseled regarding accommodating residents’ dietary preferences/requests, working collaboratively with others, and professional speech and conduct, among other topics.

Based on interviews and records, the preponderance of evidence shows licensee did not give R1, R2, R3, and R4 their medications as prescribed, and that S1 did not treat R1 with dignity. 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: 2 of 7
Control Number 08-AS-20210714132834
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
87465(a)(4)
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87465 Incidental Medical and Dental Care: “(a)(4) The licensee shall assist resident with self-administered medications as needed.” This requirement was not met, as evidenced by:
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Licensee agreed to retrain all current nurses and med techs to: a) contact the facility’s contracted pharmacy for refills whenever a resident is down to 5 days of medication remaining, b) elevate the matter to the Resident Services Director or Executive Director for follow up when residents are down to 3 days of medication remaining and the refill has not yet arrived, and c) notify residents’ physicians and seek their guidance regarding any missed medicine dose, and to document such communications in progress notes. Licensee agreed to send a copy of the training sign-in sheet and any handouts used to LPA by the POC due date.
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Based on interviews and records reviewed, the licensee did not assist 4 of 58 residents in care (R1, R2, R3, and R4) with self-administered medications as needed, which posed a potential health risk to persons in care.
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Type B
02/23/2023
Section Cited
CCR
87468.1(a)(1)
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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: (1) To be accorded dignity in their personal relationships with staff…”
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Licensee explained S1’s employment at the facility ended in May 2021. Licensee agreed to use a third-party source to retrain its current managers and line staff on Residents’ Personal Rights (as described in regulations 87468.1 and 87468.2). Licensee agreed to send a copy of the training sign-in sheet (which will include the instructor’s full name, signature, and agency) and any handouts used to LPA by the POC due date.
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This requirement was not met, as evidenced by: Based on interviews and records reviewed, licensee’s staff (S1) did not accord dignity to 1 of 58 residents (R1) in care, which posed 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: 6 of 7
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
07/14/2021 and conducted by Evaluator Dang Nguyen
COMPLAINT CONTROL NUMBER: 08-AS-20210714132834

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:
10:30 AM
MET WITH:Business Office Director Susan Dizon.TIME COMPLETED:
11:50 AM
ALLEGATION(S):
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-Facility staff did not follow resident's dietary order.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced subsequent visit to deliver a finding regarding the above prior complaint allegation. 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 facility staff did not serve Resident #1 (R1) a specific food diet ordered by their physician. CCLD’s investigation involved multiple unannounced facility tours/welfare checks, interviews of R1 and pertinent staff, and review of relevant hospital and facility care records.

[CONTINUED ON LIC 9099-C]
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: 4 of 7
Control Number 08-AS-20210714132834
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]

CCLD reviewed R1’s two LIC602 Physician’s Reports, dated 03-26-2020 and 01-06-2021: on both documents, for the box titled “Special Diet,” the physician checked “No.” R1’s LIC603 Preplacement Appraisal did not indicate a physician-prescribed special diet. The Preadmission Resident Assessment which licensee completed on R1 said they were on a “regular” diet. R1’s Service / Care Plan said they were “independent with meals and eating and drinking” and “Diet: Regular.” CCLD reviewed the facility’s care file on R1 but encountered no evidence of R1 being on a physician-prescribed special diet.

Based on interviews and records, there does not exist a preponderance of evidence to show that facility staff did not follow a physician’s dietary order for R1. The allegation is 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: 5 of 7