374604267-8-22-2024-08-AS-SJAB-D8EMGB-20240823093539

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604267
Report Date: 08/21/2024
Date Signed: 08/22/2024 08:20:10 AM

Substantiated

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
07/31/2024 and conducted by Evaluator Daniel Pena

COMPLAINT CONTROL NUMBER: 08-AS-20240731124908

FACILITY NAME:	CLOISTERS OF THE VALLEY, LLC		FACILITY NUMBER:	374604267
ADMINISTRATOR:	DISHA FRANCES-HALL		FACILITY TYPE:	740
ADDRESS:	4171 CAMINO DEL RIO SOUTH		TELEPHONE:	(619) 283-2226
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92108
CAPACITY:	70	CENSUS: 53	DATE:	08/21/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Suzie Dizon, Business Office Director		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Staff did not notify responsible party of resident's change in care

INVESTIGATION FINDINGS:

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On 8/21/24, at about 9:00 AM, Licensing Program Analyst (LPA) Daniel Pena conducted a complaint investigation visit to the facility. After identifying himself, and explaining the purpose of the visit, LPA was allowed inside the facility. LPA discussed the elements of the complaint with Business Office Director, Suzie Dizon.

On 07/31/2024, the Department received this complaint which alleged staff did not notify the responsible party of a resident's change in care. The Department's investigation included facility visits, interviews with residents, staff and outside sources and review of pertinent facility and outside agency records.

Information obtained showed that staff transferred Resident 1 (See LIC811 to identify R1) from a private room to a shared room on July 22, 2024. Interviews with staff and an outside source revealed that on May 16,

(CONTINUED ON LIC9099D)

Substantiated

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: 08/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024

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-20240731124908

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: 08/21/2024

NARRATIVE

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(CONTINUED FROM LIC9099)

2024, a care conference was held regarding R1. The interviews revealed that facility staff informed an outside source that R1 was no longer eligible for a private room at the rate they were paying. Staff informed the source that the facility would be transferring R1 to a shared room. All interviews consistently reported that no date was given by the facility as to when R1’s room transfer would occur. Per interviews, no minutes were taken of this meeting. Interviews revealed that R1 was transferred to a shared room on July 22, 2024.

When interviewed, staff said they did not present R1’s representative with a 30-day written notice of transfer. When interviewed, staff said they thought the May 16th care conference was all that was necessary. As a result of this investigation, staff expressed an understanding that they should have provided written notice of the transfer as per the resident’s admission agreement. A review of R1’s Residence and Care Agreement reads as follows, “We will provide you with thirty (30) days' written notice before substituting your Apartment.”

Based on interviews with residents, staff and outside sources and record reviews, the Department’s investigation yielded sufficient evidence to confirm the allegation that staff did not notify the responsible party of a resident's change in care. The Preponderance of Evidence standard has been met. Therefore, the allegation is Substantiated. California code of Regulations, Title 22, Division 6 & Chapter 1 is being cited on the attached LIC 9099D.

LPA investigated a secondary element of this complaint regarding a resident’s payment obligation to the facility. Interviews and record reviews revealed that changes had occurred with the resident’s supplemental funding agency. A review of records and interviews revealed that the issue does not fall within the jurisdiction of CCLD. No additional investigation was conducted into this portion of the complaint nor was a finding made. LPA advised all pertinent parties.

An exit interview was conducted and a copy of this report along with the Licensee Rights (LIC 9058 01/16) were provided to Director, Suzie Dizon, whose signature below confirms receipt of these rights.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20240731124908

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/21/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/23/2024 Section Cited CCR 87468.2	1 2 3 4 5 6 7	...Residents in Privately Operated Facilities...shall have...the following personal rights:(16) To written notice of any room changes at least 30 days in advance unless a room change...The requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee will present proof of vendorized training for all staff and management personnel regarding Personal Rights and provide written evidence to CCLD by the POC due date.
	8 9 10 11 12 13 14	Based on interviews and record reviews, the facility did not provide Resident 1 written notice of a room change. This posed a potential Person Rights risk to 1 of 66 residents 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: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024

LIC9099 (FAS) - (06/04)

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