374604267-11-27-2023-08-AS-DNGN-CXYS2R-20231127122959

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604267
Report Date: 11/27/2023
Date Signed: 11/27/2023 12:30:25 PM

Document Has Been Signed on 11/27/2023 12:30 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, LLC		FACILITY NUMBER:	374604267
ADMINISTRATOR:	GONZALEZ, JEFF		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:	11/27/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Business Office Director Susie Dizon		TIME COMPLETED:	12:40 PM

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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Business Office Director Susie Dizon. LPA also spoke with Executive Director Disha Hall via phone during the visit.

Today's visit was in response to an SOC341 Report of Suspected Dependent Adult/Elder Abuse, which licensee self-submitted to the CCLD San Diego Regional Office (received on 07/24/2023), involving Resident #1 (R1) and Staff #1 (S1). [See LIC 811 Confidential Names List for a description of person identifiers used in this report].

During today’s visit, LPA performed a brief facility tour and welfare check. LPA reviewed and collected copies of pertinent facility personnel and care records, and reviewed police correspondence. LPA also interviewed relevant facility staff.

By the date of LPA’s site visit, R1 had since moved out of the facility, and they could not be reached for interview. However, per R1’s latest LIC602 Physician’s Report (dated 04/28/2022): R1 had no cognitive impairment diagnosis and their doctor determined they were not confused/disoriented, able to follow instructions, able to communicate needs, and able to manage their own cash and economic resources. The LIC603 Preplacement Appraisal (dated 05/10/2022) and the Care Plan (dated 09/15/2022) which licensee performed also showed R1 was able to express themselves and communicate verbally “without difficulty.” Interview of the facility administrator corroborated that R1 was “alert and oriented X4.”

[CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 11/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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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: 11/27/2023

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[CONTINUED FROM LIC 809]

Records and interviews showed: During July 2023, while R1 resided at the facility, R1 had privately given S1 permission to drive/operate their automobile outside of work for the purpose of finding an alternate residence for R1. On 07/20/2023, R1 first reported to facility management that they had earlier loaned their car to S1, and since lost phone contact with S1 over multiple days, causing R1 distress. Upon learning of the incident, facility management timely suspended R1’s employment, commenced an internal investigation, and reported the incident to the San Diego Police Department (SDPD) and CCLD. On 07/21/2023, R1’s automobile was returned to them (via the care of their responsible person). While SDPD did not pursue criminal charges, Licensee’s internal investigation concluded that S1 had engaged in “misappropriation of resident property.” S1’s employment administratively ended on 08/09/2023.

A preponderance of evidence exists to show that during the incident in question, licensee’s staff (S1) used R1’s automobile beyond the scope of their consent/permission, resulting in R1’s temporary loss of control of property, and causing R1 distress. One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the licensee.

An exit interview was conducted with Dizon. A copy of this report, the LIC 809-D, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided to Dizon and Hall during the visit.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 11/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/27/2023 12:30 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: 11/27/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/28/2023 Section Cited CCR 87468.2	1 2 3 4 5 6 7	87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: “(a)…residents…shall have all of the following personal rights: “(25) To protection of their property from theft or loss…” This requirement was not met, as evidenced by:	1 2 3 4 5 6 7	Per personnel records and manager interviews: S1’s employment was suspended on 07/21/2023, and was administratively ended on 08/09/2023. This resolved the immediate risk. Licensee agreed to retrain its remaining facility staff on Resident’s Personal Rights (as articulated in CCLD form LIC613C-2), and to E-mail LPA a copy of the training sign-in sheet by 12/27/2023.
	8 9 10 11 12 13 14	Based on records and interviews, licensee’s staff (S1) did not ensure that 1 of 62 residents (R1) had their personal property protected from loss of control, which posed an immediate personal rights 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 Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 11/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023

LIC809 (FAS) - (06/04)

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