374604267-3-28-2024-08-AS-SJAB-D3STLG-20240328144930

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604267
Report Date: 03/27/2024
Date Signed: 03/28/2024 12:59:14 PM

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
12/24/2020 and conducted by Evaluator Daniel Pena

COMPLAINT CONTROL NUMBER: 08-AS-20201224134935

FACILITY NAME:	CLOISTERS OF THE VALLEY, LLC		FACILITY NUMBER:	374604267
ADMINISTRATOR:	KELLY, CHANNA		FACILITY TYPE:	740
ADDRESS:	4171 CAMINO DEL RIO SOUTH		TELEPHONE:	(619) 283-2226
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92108
CAPACITY:	70	CENSUS: 63	DATE:	03/27/2024
		UNANNOUNCED	TIME BEGAN:	12:05 PM
MET WITH:	Tia Suuronen-Goodwin, Executive Director		TIME COMPLETED:	01:10 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Medications are not being administered by appropriately skilled professionals
Staff are not following physician's orders
Residents are not accorded dignity in relationships with staff
Staff are not meeting incontinence needs of residents

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Daniel Pena conducted an unannounced visit to deliver findings for the aforementioned allegations referenced in this complaint investigation. LPA identified himself and discussed the purpose of the visit with Executive Director, Tia Suuronen-Goodwin.

On December 24, 2020, Community Care Licensing (CCL) received a complaint alleging resident medications were not administered by skilled professionals, staff did not follow physician medication orders; did not provide incontinence assistance and did not accord residents dignity.

During the investigation, LPA conducted a facility tour, obtained and reviewed copies of resident and staff records and facility documentation and interviewed pertinent staff and outside sources. Three of the four employees named in this complaint no longer work for the facility. Efforts were made to interview the former employees but not all were cooperative. Those providing statements denied participating in or witnessing other staff commit the alleged activities. Outside sources did not provide supporting

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: 03/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024

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 2

Control Number 08-AS-20201224134935

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: 03/27/2024

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

evidence or information to corroborate the allegations. Records reviewed included documented evidence that medication staff received medication training. No staff or outside source provided testimonies to support the allegations that staff was not properly trained to administer medications or did not follow physician medication orders. No interviews provided corroboration to the claim that staff did not provide incontinence care as needed. Interviews also did not provide first hand observation that staff did not treat residents with dignity.

The Department has investigated the aforementioned allegations. The preponderance of evidence standard was not met which means, the allegations may have occurred, but insufficient information was obtained to support them. Based on interviews and record reviews, the allegations are Unsubstantiated.

An exit interview was conducted with Director, Tia Suuronen-Goodwin, to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2