374604291-10-31-2023-08-AS-DPOL-CX5VE2-20231031162136

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604291
Report Date: 10/31/2023
Date Signed: 10/31/2023 02:00:59 PM

Unsubstantiated

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
08/21/2020 and conducted by Evaluator Dawn Segura

COMPLAINT CONTROL NUMBER: 08-AS-20200821120551

FACILITY NAME:	CADENCE AT POWAY GARDENS - THE PINES		FACILITY NUMBER:	374604291
ADMINISTRATOR:	BOTTOM, JASON		FACILITY TYPE:	740
ADDRESS:	12750 MONTE VISTA RD		TELEPHONE:	(800) 811-9595
CITY:	POWAY	STATE: CA	ZIP CODE:	92064
CAPACITY:	6	CENSUS: 6	DATE:	10/31/2023
		UNANNOUNCED	TIME BEGAN:	11:11 AM
MET WITH:	Donelle Williams, Executive Director		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Lack of supervision resulting in a physical altercation between residents.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Dawn Segura conducted an unannounced visit to deliver investigative findings. LPA was granted entry into the facility and met with Donelle Williams, Executive Director, and Sherryl Anding, Health Services Director, to whom she disclosed the reason for the visit.

Community Care Licensing (CCL) has investigated the above-listed complaint allegation. The investigation consisted of a tour of the facility, review of facility records and interviews of staff and outside source.

It was reported to Community Care Licensing that a couple who were married and shared a room in the facility were heard involved in an altercation in their shared room during which one resident bit the other resident. The investigation yielded evidence that confirmed the aforementioned information. The investigation also yielded that the two residents had a history of aggressive behavior between the two of them, but the couple did not desire to be apart. In response to the ongoing interactions between the

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dawn Segura	TELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023

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-20200821120551

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: CADENCE AT POWAY GARDENS - THE PINES	FACILITY NUMBER: 374604291
	VISIT DATE: 10/31/2023

NARRATIVE

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residents, additional supervision was provided; however, the aggression and altercations continued to occur. Based upon interviews conducted and records reviewed, there was not sufficient evidence to conclude that altercations between the residents occurred because of lack of supervision.

Accordingly, the allegation identified above is unsubstantiated. This finding means that there is not a preponderance of evidence to prove that the alleged violation occurred.

An exit interview was conducted with Donelle Williams, and copies of this report and Licensee/Appeal Rights (LIC 9058) were provided to the Executive Director at the conclusion of the visit. Her signature below serves as acknowledgment of receipt of copies of the report and rights.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dawn Segura	TELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023

LIC9099 (FAS) - (06/04)

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