374604288-8-31-2022-08-AS-DSEA-CHTSA4-20220831134143

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604288
Report Date: 08/30/2022
Date Signed: 08/31/2022 01:41:53 PM

Document Has Been Signed on 08/31/2022 01:41 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	CADENCE AT POWAY GARDENS - THE PALMS		FACILITY NUMBER:	374604288
ADMINISTRATOR:	BOTTOM, JASON		FACILITY TYPE:	740
ADDRESS:	12708 MONTE VISTA RD		TELEPHONE:	(858) 312-8492
CITY:	POWAY	STATE: CA	ZIP CODE:	92064
CAPACITY:	24	CENSUS: 16	DATE:	08/30/2022
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME BEGAN:	04:28 PM
MET WITH:	Donelle Williams, Executive Director		TIME COMPLETED:	06:00 PM

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	Licensing Program Analyst (LPA) Dawn Segura conducted an unannounced case management visit. LPA was granted entry into the facility by Lana Carroll, Medication Care Partner, and met with Donelle Williams, Executive Director, to whom she disclosed the purpose of the visit. This visit was initiated to cite for a deficiency that is being issued in response to a self-reported incident that occurred on January 28, 2021, in which Resident #1 (R1) [LIC 811 Confidential Names List was provided to identify the resident] was absent without leave (AWOL) from the facility and returned to the facility on the same day with no reported injuries. It was reported to Community Care Licensing by a facility staff member who had authority to report on behalf of the licensee that, at approximately 4:35 PM on January 29, 2021, R1, a resident of the facility, was found outside of Cadence at Poway Gardens–The Palms (“The Palms”) by an outside party. When found wandering on the sidewalk, R1 provided his/her name to the outside party and indicated to the outside party that he/she lived in Cadence at Poway Gardens–Mountain Vistas (“Mountain Vistas”). The outside party returned R1 to Mountain Vistas, where R1 was received by the facility’s Resident Services Director. During a previous visit to the facility, it was reported to LPA that during the time that staff were serving dinner, at approximately 4:20 PM, R1 who has a diagnosis of dementia, walked out of the facility. While in the enclosed patio on the front of the building, R1 walked to the end of the patio where a gate, to which only a limited number of staff have means of unlocking, had been left ajar or propped open by an undetermined facility staff. It is presumed that R1 walked out of the open gate, through an adjacent parking lot, and reached the sidewalk where, while walking, R1 encountered an outside party who worked in the area. The outside party asked R1 where he/she resided, and R1 pointed across the street at Mountain Vistas. The outside party escorted R1 to Mountain Vistas, where R1, who appeared to be unharmed, was greeted and received by the Resident Services Director. Subsequently, R1 was safely transported across the street and

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dawn Segura	TELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022

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

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: CADENCE AT POWAY GARDENS - THE PALMS	FACILITY NUMBER: 374604288
	VISIT DATE: 08/30/2022

NARRATIVE

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returned to The Palms. Based upon information obtained while conducting interviews, R1 was absent without supervision for approximately 15 minutes.

During today’s visit, LPA observed the gate through which R1 exited to be locked with no means of unattended resident egress.

A deficiency is being cited on the attached LIC 809-D in accordance with Title 22 of the California Code of Regulations. This report was discussed with Donelle Williams, Executive Director, at the end of the visit. Copies of the report and Licensee/Appeal Rights were provided to the Executive Director at the conclusion of the visit. Her signature on this report acknowledges receipt of copies of the rights and report.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dawn Segura	TELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/31/2022 01:41 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: CADENCE AT POWAY GARDENS - THE PALMS	FACILITY NUMBER: 374604288
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/30/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/16/2022 Section Cited	1 2 3 4 5 6 7	Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by:
	8 9 10 11 12 13 14	Based on interviews and record review, the licensee did not have competent staff to provide the services necessary to meet resident needs for 14 of 14 persons in care which posed potential health, safety, and personal rights risks to persons in care.	8 9 10 11 12 13 14	conducted more frequently. The frequency of perimeter gate checks has been increased, and ED offered to create a log to document gate checks on each shift. Resident supervision training will be conducted by an outside vendor, and proof of staff training will be provided to CCL by the POC due date.
	1 2 3 4 5 6 7
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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: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dawn Segura	TELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022

LIC809 (FAS) - (06/04)

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