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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604289
Report Date: 03/21/2024
Date Signed: 03/21/2024 10:48:26 AM


Document Has Been Signed on 03/21/2024 10:48 AM - 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:POWAY GARDENS SENIOR LIVING - MOUNTAIN VISTASFACILITY NUMBER:
374604289
ADMINISTRATOR:BOTTOM, JASONFACILITY TYPE:
740
ADDRESS:12695 MONTE VISTA RDTELEPHONE:
(858) 312-5406
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY:32CENSUS: 11DATE:
03/21/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Donelle Williams, Executive DirectorTIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analysts (LPAs) Dawn Segura and Adrian Mangina conducted an unannounced case management visit. LPAs were granted entry into the facility and met with Donelle Williams, Executive Director, to whom LPA Segura 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 June 24, 2021, and facility staff became aware of on June 25, 2021, in which Resident #1 (R1) [LIC 811 Confidential Names List was provided to identify the resident] was inappropriately touched in a sexual manner by Staff #1 (S1).

On June 25, 2021, 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 4:30 PM on June 24, 2021, S1 had been observed standing beside R1 with S1’s arm around R1’s waist. S1 was observed moving his/her arm below R1’s waist and rubbing his/her hand on R1’s buttocks in a circular motion.

The investigation consisted of interviews of facility staff and outside sources and review of facility and outside source records. Evidence collected during the investigation revealed that R1 had a diagnosis of dementia and was not in a cognitive state to have the ability to consent to such interaction at the time that the incident occurred. The investigation also yielded that, while there were other incidents observed that did not rise to the level of a sexual nature, S1 interacted in an inappropriate manner with residents on other occasions.

Based upon the foregoing, 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 form acknowledges receipt of the rights and a copy of this report.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dawn SeguraTELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2024
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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Document Has Been Signed on 03/21/2024 10:48 AM - 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: POWAY GARDENS SENIOR LIVING - MOUNTAIN VISTAS
FACILITY NUMBER: 374604289

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/04/2024
Section Cited
CCR
87468.2(a)(8)

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. . .residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse.
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Executive Director informed LPA that S1 was terminated following the incident. Executive Director provided LPA proof of Resident Personal Rights training that was provided to all staff on 3/4/2024.
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This requirement was not met, as evidenced by:
Based on interviews and record review, the licensee did not ensure that R1, 1 of 17 residents in care, was kept free from sexual abuse, which posed a potential personal rights risk to a person in care.
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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 TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dawn SeguraTELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2024
LIC809 (FAS) - (06/04)
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