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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604273
Report Date: 05/22/2024
Date Signed: 05/22/2024 02:34:15 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
03/08/2021 and conducted by Evaluator Becky Kennedy
COMPLAINT CONTROL NUMBER: 08-AS-20210308094715
FACILITY NAME:CASA MAHALFACILITY NUMBER:
374604273
ADMINISTRATOR:FRAZIER, THERESAFACILITY TYPE:
740
ADDRESS:12631 CASA AVENIDATELEPHONE:
(858) 924-1136
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY:6CENSUS: 6DATE:
05/22/2024
UNANNOUNCEDTIME BEGAN:
01:19 PM
MET WITH:Teresita DuclayanTIME COMPLETED:
03:05 PM
ALLEGATION(S):
1
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9
Staff administered a PRN without consulting a physician
INVESTIGATION FINDINGS:
1
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5
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7
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10
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13
Licensing Program Analyst Becky Kennedy concluded the investigation which began on 3/18/21. LPA Kennedy made an unannounced visit to the above facility today and met with Teresita Duclayan,caregiver. LPA advised them of the reason for today's visit and delivered the investigation findings on the above allegations.
The investigation consisted of interviews with internal sources, a review of documents, and a tour of the facility.

It was alleged that Resident 1 (R1) received PRN (As needed) medication without consulting a physician.
Interviews with internal and external sources revealed that R1 was not able to express their needs for PRN medication. It was further revealed that facility staff would assist R1 using an inhaler when they displayed signs of breathing difficulty.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Icela EstradaTELEPHONE: (619) 688-6866
LICENSING EVALUATOR NAME: Becky KennedyTELEPHONE: 619-672-5843
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024
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 4
Control Number 08-AS-20210308094715
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: CASA MAHAL
FACILITY NUMBER: 374604273
VISIT DATE: 05/22/2024
NARRATIVE
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The allegation that the staff administered a PRN without consulting a physician is substantiated. The investigation did not reveal any adverse outcomes. LPA determined that there was no negative impact to R1 or other residents and did not affect the overall operation of the facility. This is considered a technical violation and no citation is being issued at this time.

An exit interview was conducted with Teresita Duclayan,caregiver. A copy of this report along with Licensee Rights (LIC9058 01/2016) was left at the facility.
SUPERVISOR'S NAME: Icela EstradaTELEPHONE: (619) 688-6866
LICENSING EVALUATOR NAME: Becky KennedyTELEPHONE: 619-672-5843
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
03/08/2021 and conducted by Evaluator Becky Kennedy
COMPLAINT CONTROL NUMBER: 08-AS-20210308094715

FACILITY NAME:CASA MAHALFACILITY NUMBER:
374604273
ADMINISTRATOR:FRAZIER, THERESAFACILITY TYPE:
740
ADDRESS:12631 CASA AVENIDATELEPHONE:
(858) 924-1136
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY:6CENSUS: DATE:
05/22/2024
UNANNOUNCEDTIME BEGAN:
01:19 PM
MET WITH:TIME COMPLETED:
03:05 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff failed to address a change in condition
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst Becky Kennedy concluded the investigation which began on 3/18/21. LPA Kennedy made an unannounced visit to the above facility today and met with Teresita Duclayan,caregiver. LPA advised them of the reason for today's visit and delivered the investigation findings on the above allegation.

The investigation into the above allegations consisted of interviews with internal sources, and a tour of the facility.
It was alleged that Resident 1 (R1) was ill with a condition that required antibiotics to treat, and the facility did not address the concern.

Interviews with internal and external sources revealed that R1 has two conditions that affects their breathing. R1 has a prescribed inhaler to assist with breathing as needed.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Icela EstradaTELEPHONE: (619) 688-6866
LICENSING EVALUATOR NAME: Becky KennedyTELEPHONE: 619-672-5843
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 08-AS-20210308094715
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: CASA MAHAL
FACILITY NUMBER: 374604273
VISIT DATE: 05/22/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
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32
R1 was being discharged from the facility. The individual transporting R1 noted that R1 was having breathing difficulties and took R1 to a medical provider and antibiotics were prescribed. R1 was not admitted to the hospital.

Interviews revealed that R1 used their inhaler that morning. This is not unusual for R1. One of two individuals with knowledge of R1’s condition prior to R1 leaving the facility reported that R1 might have been getting a cold. The other reported that R1 was "normal".

The investigation revealed no evidence to indicate that R1’s had a noticeable change in condition in the days prior to R1’s discharge.

The preponderance of evidence standard has not been met to confirm that the staff failed to address a change in condition and this allegation is unsubstantiated.

An exit interview was conducted with Teresita Duclayan,caregiver. A copy of this report along with Licensee Rights (LIC9058 01/2016) was left at the facility.
SUPERVISOR'S NAME: Icela EstradaTELEPHONE: (619) 688-6866
LICENSING EVALUATOR NAME: Becky KennedyTELEPHONE: 619-672-5843
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4