<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604292
Report Date: 05/20/2022
Date Signed: 05/20/2022 11:10:08 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
11/23/2021 and conducted by Evaluator Esther Miller
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20211123082525
FACILITY NAME:CADENCE AT POWAY GARDENS - THE MAPLESFACILITY NUMBER:
374604292
ADMINISTRATOR:BOTTOM, JASONFACILITY TYPE:
740
ADDRESS:12725 MONTE VISTA RDTELEPHONE:
(858) 487-4067
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY:6CENSUS: 5DATE:
05/20/2022
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Donnelle Williams, Executive DirectorTIME COMPLETED:
11:20 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility did not follow admissions agreement.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Esther Miller conducted an unannounced complaint investigation visit to the facility in order to deliver findings on the above allegation. LPA was granted entry to the facility by Donnelle Williams, Executive Director, after identifying herself and explaining the reason for the visit.

On November 23, 2021, it was alleged that the facility did not follow an admission agreement, by not providing a promised room to a resident as agreed upon at admittance. The Department’s investigation consisted of review of facility and outside source records and interviews of facility staff and outside sources.

[Continued on LIC9099-C]
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther MillerTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022
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 5
Control Number 08-AS-20211123082525
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 MAPLES
FACILITY NUMBER: 374604292
VISIT DATE: 05/20/2022
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
26
27
28
29
30
31
32
[Continued from LIC9099]
Around September 7, 2021, Resident 1 (R1) and a family member came to the facility for a possible relocation. R1 was given a tour of suite Maples 1. Facility records showed that suite Maples 1 was a large room with a private bathroom but was occupied at the time. Investigative interviews revealed that suite Pines 1 was also a large room with a private bathroom and which the facility expected to be vacant on October 3, 2021. Staff and outside source interviews confirmed that Resident 2 (R2), who lived in suite Pines 1, had given a 30-day Notice to Vacate and was expected to move out around October 3, 2021.

Facility records showed that, on September 7, 2021, Community Relations Director initialed and dated a signed Community Fee Receipt for R1 with the note “Move to Pines 1 in Oct. 3 2021”. The document was signed by a community representative and R1’s authorized representative. A copy was provided to R1 as part of the terms and conditions of resident admission. Staff and outside source interviews confirmed that R1 moved into room Maples 5 temporarily with the expectation that R1 would ultimately move into suite Pines 1 on October 3, 2021. Facility records also showed that, on September 9, 2021, an Admissions Agreement was signed on behalf of R1 who then moved into room Maples 5 on September 10, 2022 at a rate of $7300 a month. Room Maples 5 was smaller than suite Pines 1 and did not have a private bathroom. Other facility records also included notations that R1 was expected to eventually move into room Pines 1 at a rate of $7500 per month.

Staff and outside source interviews confirmed that R2 requested an extension on their 30-day Notice to Vacate, making the suite Pines 1 unavailable for R1 to move into on October 3, 2021. On October 8, 2021, staff and outside source interviews confirmed that R1’s representative gave the facility a 30-day Notice to Vacate due to R1 not being moved into suite Pines 1 as agreed upon in writing at the time of admission. Outside source interviews and records showed that R1 moved out of the facility on October 31, 2021. Staff interviews revealed that R2 subsequently moved out of the facility on October 15, 2021.

Based on the evidence obtained during the complaint investigation, the allegation that the licensee did not follow their admissions agreement is found to be SUBSTANTIATED, as there is a preponderance of evidence to show that the violation occurred. Pursuant to the California Code of Regulations, Title 22,
Division 6, deficiency is being cited on the attached LIC9099D and a plan of correction was jointly developed with Executive Director. An exit interview was conducted with Executive Director; a copy of this report, Licensee's Rights (LIC9058), LIC9099-C, and LIC9099-D were provided to Executive Director.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther MillerTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 08-AS-20211123082525
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 MAPLES
FACILITY NUMBER: 374604292
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/20/2022
Section Cited
CCR
87507(f)
1
2
3
4
5
6
7
87507(f) ADMISSION AGREEMENTS: The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Internal training provided to Administrative staff regarding Admissions Agreement and what constitutes modifications to the Admission Agreement. Executive Director will send proof of staff training.
8
9
10
11
12
13
14
Based on interviews and record reviews, the licensee did not comply with terms and conditions of admissions agreement in one of five residents which posed a potential personal rights risk to residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther MillerTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
11/23/2021 and conducted by Evaluator Esther Miller
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20211123082525

FACILITY NAME:CADENCE AT POWAY GARDENS - THE MAPLESFACILITY NUMBER:
374604292
ADMINISTRATOR:BOTTOM, JASONFACILITY TYPE:
740
ADDRESS:12725 MONTE VISTA RDTELEPHONE:
(858) 487-4067
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY:6CENSUS: 5DATE:
05/20/2022
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Donnelle Williams, Executive DirectorTIME COMPLETED:
11:20 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility did not provide adequate room accommodations for resident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Esther Miller conducted an unannounced complaint investigation visit to the facility in order to deliver findings on the above allegation. LPA was granted entry to the facility by Janice Amores, caregiver, after identifying themselves and explaining the reason for the visit. LPA met with Donnelle Williams, Executive Director, later during the visit.

On November 23, 2021, it was alleged that the facility did not provide adequate room accommodation. More specifically that the room was not approved to house a resident, that the room contained an electrical box, and that the room was too small for their furniture. The Department’s investigation consisted of LPA observations, review of facility and outside source records, photographs, and interviews of facility staff and outside sources.

[Continued on LIC9099-C]
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther MillerTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022
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 5
Control Number 08-AS-20211123082525
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 MAPLES
FACILITY NUMBER: 374604292
VISIT DATE: 05/20/2022
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
26
27
28
29
30
31
32
[Continued from LIC9099-A]

Around September 7, 2021, Resident 1 (R1) and their family member came to the facility for a possible relocation. Facility records show that, on September 9, 2021, an Admissions Agreement was signed for R1 who then moved into room Maples 5 on September 10, 2021. Room Maples 5 was small and did not have a private bathroom. Outside source interviews and records show that R1 moved out of the facility on October 31, 2021. Facility records and investigative interviews report that R1 is diagnosed with dementia.

LPA Miller observed on May 20, 2022 that room Maples 5 was a 10ftx12ft resident room that was clean and appeared sanitary. Room Maples 5 had one window that was in good repair and clean with working blinds. The room had carpeting and two lamps. Room Maples 5 had a shared bathroom with room Maples 4. Room Maples 5 contained a bed, a chair, a dresser, a night stand, and a television. The television worked correctly and had a working remote control. Bedroom was large enough to allow for easy passage between and comfortable usage of bed and furniture. LPA entered room Maples 5 from the facility’s hallway. LPA saw that the only other exit for room Maples 5 was a working alarmed door that led outside to the front of the facility’s covered porch that was enclosed in a green fence. The current resident had a dog bed in front of that exit. LPA did not observe any metal box on the wall. Facility sketch shows that room Maples 5 had approved non-ambulatory fire clearance for residents to reside in. LPA observed that there was sufficient room available to accommodate ambulatory residents to be served in comfort and safety.

Based on the evidence obtained during the complaint investigation, the allegation that the licensee did not provide adequate room accomodations is found to be UNSUBSTANTIATED, meaning that although the allegation may have happened or may be valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the Department has dismissed the above allegation. An exit interview was conducted with Donnelle Williams, Executive Director; a copy of this report and Licensee's Rights (LIC9058) were provided to Executive Director.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther MillerTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5