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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604267
Report Date: 04/26/2023
Date Signed: 04/26/2023 05:24:29 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
05/18/2022 and conducted by Evaluator Rebecca A Ruiz
COMPLAINT CONTROL NUMBER: 08-AS-20220518151446
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: 62DATE:
04/26/2023
UNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Resident Services Director River PagalaTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Licensee did not treat resident with dignity
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced complaint visit to conduct follow up regarding the above mentioned allegation. LPA was greeted by, identified herself to, and explained the purpose of the visit and the basic elements of the complaint with Resident Services Director River Pagala.

During today’s visit, LPA observed residents in care and interviewed residents and staff.

The Department's investigation consisted of interviews with residents, staff, and outside sources, records review, and a tour of the facility. It was alleged that the Licensee did not treat resident with dignity. Interviews and records review revealed that Resident 1 (R1) had a physician prescribed diet. Interviews revealed that Staff 1 (S1) accused R1 of not complying with the physician prescribed diet and that S1 would cancel R1's outside grocery services.
Continued on LIC9099-C page...
Substantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023
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 5
Control Number 08-AS-20220518151446
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: 04/26/2023
NARRATIVE
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Interviews revealed that S1 interacted with residents in a manner that they considered rude, such as not engaging in small talk or acknowledging their greetings. Interviews revealed that S1 did not attempt to engage residents in a polite manner which came off as rude to residents.

The Department has investigated the above-mentioned allegation and based on interviews, the preponderance of the evidence has been met, therefore, this allegation is deemed substantiated. The following deficiency is cited per CA Code of Regulations Title 22 and noted on the attached LIC9099-D page.

An exit interview was conducted with Resident Services Director River Pagala, to whom a copy of this report and the Licensee Appeal Rights (LIC9058 01/16) were provided via hard copy.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 08-AS-20220518151446
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: 04/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/26/2023
Section Cited
CCR
87468.1(a)(1)
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87468.1 Personal Rights of Residents in All Facilities (a)(1) to be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement has not been met as evidenced by:
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RSD will schedule a personal rights training for staff and will provide a sign in sheet to LPA by POC due date.
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Based on interviews, the Licensee did not ensure that R1 was accorded dignity in their relationship with staff. This poses a potential personal rights risk to 62 of 62 residents 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: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
05/18/2022 and conducted by Evaluator Rebecca A Ruiz
COMPLAINT CONTROL NUMBER: 08-AS-20220518151446

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: 62DATE:
04/26/2023
UNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Resident Services Director River PagalaTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Illegal Eviction
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegation. LPA identified herself to, was greeted by, and explained the purpose of the visit to Resident Services Director River Pagala.

The Department’s investigation consisted of interviews with residents, staff, and outside sources, records review, and a tour of the facility. It was alleged that the facility unlawfully evicted a resident. Records review revealed that Resident 1 (R1) had a diagnosis of diabetes and had a physician prescribed diet. Review of records and interviews revealed that in May 2022, staff observed that R1 had not complied with R1’s diet and had issues with R1 ordering and receiving medications in a timely manner resulting in several medications not being available for administration. Interviews and record review revealed that in May 2022, R1 was observed to be unable to interpret a medical device related to the diabetes diagnosis and staff notified R1’s physician.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023
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 5
Control Number 08-AS-20220518151446
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: 04/26/2023
NARRATIVE
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Records review revealed that R1’s physician determined that R1 could no longer manage their medication and in May 2022, R1’s physician submitted a discharge order for R1 to be relocated to a skilled nursing facility to manage R1’s diabetes. R1 was relocated from the facility to a skilled nursing facility in mid-May 2022.

The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of the evidence has not been met, therefore, this allegation is deemed unsubstantiated.

An exit interview was conducted with Resident Services Director River Pagala, to whom a copy of this report and the Licensee Appeal Rights (LIC9058 01/16) were provided via hard copy.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5