374604267-11-15-2023-08-AS-SJAB-CY3Q9Z-20231130105910

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604267
Report Date: 11/15/2023
Date Signed: 11/15/2023 11:51:29 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 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
11/09/2023 and conducted by Evaluator Daniel Pena

COMPLAINT CONTROL NUMBER: 08-AS-20231109092101

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:	11/15/2023
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	River Pagala, Resident Services Director		TIME COMPLETED:	11:40 AM

ALLEGATION(S):

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Staff did not notify the authorized representative that resident had shingles

INVESTIGATION FINDINGS:

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On 11/15/2023, at about 8:45 AM, Licensing Program Analyst (LPA) Daniel Pena conducted an unannounced visit to investigate a complaint. LPA identified himself and discussed the allegation mentioned above with River Pagala, Resident Services Director.

On 11/9/2023, the Department received a complaint, alleging the licensee did not inform a resident's authorized representative they (the resident) had shingles. The Department’s investigation consisted of facility inspection, record reviews, and interviews with staff and outside sources.

According to the complaint, red spots were observed on Resident 1's (R1) body in August 2023. The facility sent a text message to an authorized representative that the facility physician prescribed a medicated ointment to address a rash on R1's body. The staff did not inform the authorized representative that R1 was diagnosed with shingles. According to the complaint, on October 31, 2023, a facility contract physician verbally advised R1's authorized representative that R1 had shingles. LPA reviewed R1's records and found

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

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

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20231109092101

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: CLOISTERS OF THE VALLEY, LLC	FACILITY NUMBER: 374604267
	VISIT DATE: 11/15/2023

NARRATIVE

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progress notes dated as early as 10/12/2023, where "a rash" was observed in R1's upper torso area. A medication was prescribed to address the condition and documented in the same entry. According to interviews with an outside source, they observed red spots on the right side of R1's upper torso. A progress note dated 10/26/2023, indicated that an outside source informed staff that R1 was experiencing a "flare up" of what looked like "shingles." The progress note indicates that staff requested documentation of the diagnosis but were only presented with a prescription that staff faxed to the pharmacy.

Another 10/26/2023 progress note entry reads that R1 received their first dose of an antibiotic. Per the Mayo Clinic, the medication named in the progress note is used to treat "the symptoms of chickenpox, shingles..." LPA obtained screen shots of text messages sent by the facility to the authorized representative which noted rashes to R1’s body. The text message stated that the facility contacted R1’s physician who prescribed a medication used to treat shingles. The facility sent the authorized representative photos of the prescribed medication and R1’s skin condition on 8/9/2023. Interviews with an outside source indicated that R1’s red spots improved once the medication was taken.

Title 22, Section 87466, Observation of the Resident, requires the licensee to ensure residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes...or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. Evidence obtained indicates that the facility did inform the authorized representative and R1’s physician of a change in R1's skin condition which was documented in facility and outside source records.

The Department has investigated the allegation that the licensee did not inform a resident's authorized representative they had shingles. Based on interviews and record reviews the investigation yielded insufficient evidence to support the allegation. The preponderance of evidence standard was not met; therefore, the allegation is deemed Unsubstantiated.

An exit interview was conducted with Resident Services Director, Pagala, and a copy of this report and Licensee/Appeal Rights (LIC 9058 01/16) were provided to Mr. Pagala at the conclusion of the visit.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

LIC9099 (FAS) - (06/04)

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