374604267-12-22-2021-08-AS-SJAB-CA8SF6-20211231124949

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604267
Report Date: 12/21/2021
Date Signed: 12/22/2021 11:48:01 AM

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
05/21/2021 and conducted by Evaluator Debbie Correia

COMPLAINT CONTROL NUMBER: 08-AS-20210521172309

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: 58	DATE:	12/21/2021
		UNANNOUNCED	TIME BEGAN:	04:21 PM
MET WITH:	Activities Director Emily De La Barre		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Unlawful eviction.
Medications not given as prescribed.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced visit to deliver investigative findings on the above listed complaint allegations. LPA was met at the front door by Caregiver Charles Dautel, identified herself, and was granted entry into the facility. LPA met with Activities Director Emily De La Barre to whom was explained the purpose for the visit and coordinated with Executive Director (ED) Channa Kelly to join the meeting via tele-conference.

The Department’s investigation consisted of staff, resident, and outside source interviews. It also consisted of facility and resident record reviews.

It was alleged facility staff are pursuing an unlawful eviction on Resident (R1). A record review revealed the facility has a contract in place with the Community Health Group (CHG), a health care service plan that provides services to beneficiaries who enroll in an associated Government funded health program. The contractual agreement, under the specified conditions, states that CHG will provide financial assistance to individuals who meet the eligibility criteria, as mentioned above, based on a compensation schedule.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie Correia	TELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021

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 4

Control Number 08-AS-20210521172309

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: 12/21/2021

NARRATIVE

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It was also alleged facility staff did not give R1 medication as prescribed. Record reviews revealed R1’s personal doctor prescribed medication and facility staff did not administer the medication for approximately two months after the date prescribed. An interview with facility staff and an outside source corroborated the delay in administering the medication to R1.

Based on the LPA’s investigation, the above allegations are determined to be substantiated. A substantiated finding means the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited per Title 22, Division 6, Chapter 8 of the California Code of Regulations and are listed on LIC 9099-D.

LPA Correia conducted an exit interview with Activities Director Emily De La Barre and Licensee Channa Kelly, to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 01/16) were provided via E-mail. An electronic email read receipt confirms the documents were received.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie Correia	TELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 08-AS-20210521172309

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: 12/21/2021

NARRATIVE

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A facility record review revealed the facility must ensure authorization from CHG to verify that the individual is eligible, and the required services to be provided are rendered as appropriate. On September 30, 2020, during facility admission, R1's Primary Care Physician (PCP), a participating member of CHG, conducted a medical assessment revealing R1 required assistance with daily living skills (ADLs), as documented on the Physician’s Report (LIC 602), that deemed R1 eligible for CHG assistance. An outside source interview revealed on January 28, 2021, that the PCP conducted a re-assessment and determined R1 no longer met the criteria for CHG assistance. The PCP stated R1's conditions had improved, and they were deemed independent. This information was relayed to R1’s Responsible Party(RP) via telephone.

A record review revealed no documentation of a re-assessment conducted by the PCP, this was corroborated by an interview with facility staff who stated the PCP observed no change in condition therefore did not complete a new Physician’s Report or document any changes in conditions. At the request of the RP a second re-appraisal was conducted by the PCP on May 21, 2021 that yielded the same results. An outside source interview revealed R1 was given a verbal eviction by the facility ED, stating that they are to move as of the date CHG ceases financial assistance. In contrary, an interview with the facility ED revealed R1 was not being evicted, however their monthly rate would be increasing from approximately $1,217.00, which is fully covered between CHG and SSI, to the private pay monthly rate of $5,000, because the facility does not accept SSI/SSP recipients/payments. A review of the California Advocates Nursing Home Reform (CANHR) Eviction Protection for RCFE’s factsheet revealed pursuant to Title 22 regulations, if the resident is an SSI/SSP recipient the RCFE shall provide basic services at the rate established for SSI/SSP recipients as stated in Title 22 California Code of Regulations.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie Correia	TELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 08-AS-20210521172309

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: 12/21/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type B 01/21/2022 Section Cited CCR 87464(e)	1 2 3 4 5 6 7	Basic Services: If the resident is an SSI/SSP recipient, then the basic services shall be provided and/or made available at the basic rate at no additional charge to the resident. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee did not provide a POC. An office meeting will be scheduled to determine the actions going forward.
	8 9 10 11 12 13 14	Based on interviews and record reviews, the Licensee did not ensure 1 of 42 residents who are SSI/SSP recipients receive basic services at the rate determined by Title 22 California Code of Regulations. This poses a potential personal rights risk to residents in care.	8 9 10 11 12 13 14
Deficiency Dismissed Type B 12/24/2021 Section Cited CCR 80075(b)(5)(B)	1 2 3 4 5 6 7	Health Related Services. Medications shall be given according to physician's directions. This requirement is not met as evidenced by: This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee will submit proof of Medication Management training and certification provided to facility staff by Ron's Pharmacy. Licensee will also submit proof of a new hire of a Licensed Vocational Nurse (LVN) to assist with medication management by POC date.
	8 9 10 11 12 13 14	Based on interviews and record reviews, the Licensee did not ensure 1 of 58 residents received their medication as prescribed. This poses a potential health risk to residents in care.	8 9 10 11 12 13 14

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: Debbie Correia	TELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021

LIC9099 (FAS) - (06/04)

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