<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604267
Report Date: 04/10/2023
Date Signed: 04/10/2023 05:05:47 PM


Document Has Been Signed on 04/10/2023 05:05 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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, LLCFACILITY NUMBER:
374604267
ADMINISTRATOR:CINDY NIEDRICHFACILITY TYPE:
740
ADDRESS:4171 CAMINO DEL RIO SOUTHTELEPHONE:
(619) 283-2226
CITY:SAN DIEGOSTATE: CAZIP CODE:
92108
CAPACITY:70CENSUS: 63DATE:
04/10/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:38 AM
MET WITH:Resident Services Director River Pagala and Lead Med Tech Marquette CorbettTIME COMPLETED:
05:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management visit. LPA was welcomed by and identified himself to Receptionist Rebecca Lane. LPA then met and discussed the purpose of the visit with Resident Services Director River Pagala and Lead Med Tech Marquette Corbett.

Today's visit was in response to an LIC624 Incident Report which licensee self-submitted to the CCLD San Diego Regional Office (RO), regarding Resident #1 (R1) being AWOL (absent without leave) from the facility on 03-27-2023. [See LIC811 Confidential Names List for a description of person identifiers used in this report.] According to the LIC624, a nearby business called police after seeing R1 in their own parking lot. R1 was picked up unharmed/uninjured by police and evaluated at a hospital (as a precaution), before being brought back to the facility on 03-28-2023.

During today’s visit, LPA briefly toured the facility and performed a welfare check on residents in care. LPA verified that R1 was indeed unharmed/uninured. LPA verified that auditory staff alert devices on the facility’s perimeter exit doors were working. LPA also reviewed pertinent administrative, care, and medical records, and interviewed R1 and relevant staff. Due to R1’s baseline short-term memory loss and disorientation to time (R1 had no recollection of the incident), they were unable to participate as a reliable historian/interviewee.

According to R1’s latest LIC602 Physician’s Report, dated 02-23-2023, R1 was diagnosed with “late onset Alzheimer’s dementia” and their doctor determined that they were not able to safely leave the facility unassisted. Per R1’s LIC603A Resident Appraisal, dated 03-11-2023, they exhibited “increased forgetfulness, confusion, and sundowning behavior that gets [worse] at night time,” and had a “history of wandering behavior.”

[CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 04/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/10/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
[CONTINUED FROM LIC 809]

Per licensee’s own Care Plan for R1, and corroborated by manager interview, R1 required visual safety checks “every 2 hours” despite needing very little ADL care. Staff progress notes/charting corroborated: from the time of R1’s move-in during mid-March 2023, through the date of their 03-27-2023 AWOL, R1 was often more confused and/or anxious in the evenings. R1 repeatedly wandered hallways to look for their children, and staff frequently redirected them.

According to the LIC624, licensee’s own internal investigation, and staff interviews: Staff #1 (S1) was R1’s assigned caregiver for PM shift on 03-27-2023. They were the last person to see R1 inside the facility leading up to the AWOL. Around 8:40 PM, S1 assisted R1 to bed, before their shift ended less than 2 hours later. Staff #2 (S2) was R1’s assigned overnight shift caregiver. S2 told licensee they performed required visual checks and saw R1 in bed at 12:00 AM midnight. However, camera surveillance footage revealed: a) S2 did not visit R1’s room as they stated, and b) R1 instead exited the facility premises around 9:09 PM. It was not until around 6:00 AM on 03-28-2023 that Staff #3 (S3), who was to be R1’s assigned caregiver on AM shift, recognized R1 was missing and alerted coworkers. Consistent with licensee’s own Absentee Notification Plan (Chapter on “Elopement” from their policy manual), staff unsuccessfully searched the facility for 30 minutes, then phoned police and R1’s responsible party.

According to licensee, the facts of their internal investigation led them to terminate S2’s employment and to discipline another (separate) staff member from their overnight shift.

CCLD’s own investigation concluded that licensee’s staff on 03-27-2023 did not provide R1 needed observation, as was described in R1’s Care Plan.

One deficiency is cited per California Code of Regulations (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the licensee.

An exit interview was conducted with Corbett. A hard copy of this report, the LIC809-D, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided to staff during today’s visit. A copy of these documents was also E-mailed to the facility administrator.

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 04/10/2023 05:05 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/10/2023
Section Cited

1
2
3
4
5
6
7
87466 Observation of the Resident: “The licensee shall ensure that residents are regularly observed…” This requirement was not met, as evidenced by:
1
2
3
4
5
6
7
Per interviews, licensee terminated S1’s employment and disciplined another staff following the incident. Licensee agreed to retrain its staff to: a) visually check on residents every few hours (more often if specified in the Care Plan), b) to account for all assigned residents by both the outgoing and incoming staff persons during shift change, and c) to verify that alarms on the facility’s perimeter exit doors are armed during shift change. Licensee agreed to E-mail LPA a copy of the training sign-in sheet by the POC due date.
8
9
10
11
12
13
14
Based on records and interviews, the licensee did not ensure that 1 of 63 residents (R1) was observed, which posed a potential safety risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 04/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3