374604294-4-29-2022-18-AS-JESL-CKNL5M-20221029082722

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604294
Report Date: 04/29/2022
Date Signed: 04/29/2022 12:00:19 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/26/2022 and conducted by Evaluator Crystal Colvin

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20220426111939

FACILITY NAME:	LAS VILLAS DEL NORTE		FACILITY NUMBER:	374604294
ADMINISTRATOR:	FARISH, JOLENE		FACILITY TYPE:	740
ADDRESS:	1325 LAS VILLAS WAY		TELEPHONE:	(760) 741-1047
CITY:	ESCONDIDO	STATE: CA	ZIP CODE:	92026
CAPACITY:	198	CENSUS: 196	DATE:	04/29/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Lorena Vivar - Assistant Executive Director		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Staff did not assist resident from fall in a timely manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced in order to initiate an investigation of a complaint with the above allegation(s). LPA identified herself and discussed the purpose of the visit and the elements of the allegation(s) with Assistant Executive Director Lorena Vivar. Below is a summary of the complaint investigation findings:

Regarding allegation "Staff did not assist resident from fall in a timely manner.": LPA Colvin reviewed resident's (R1) file, relevant facility records, and conducted interviews with parties knowledgable of the circustances surrounding the allegation and the operation of the facility. Through interviews and record review, LPA Colvin confirmed that on 4/24/22, R1 had fallen in their private room. LPA Colvin additionally confirmed that 911 was contacted by non-staff members to assist R1, as R1's pendant calls and other phone calls to the facility (to assist R1) were not being answered. Interviews additionally revealed that others called the facility on behalf of R1 at 6:16pm, but was unable to get a hold of anyone at the facility.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022

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 3

Control Number 18-AS-20220426111939

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: LAS VILLAS DEL NORTE	FACILITY NUMBER: 374604294
	VISIT DATE: 04/29/2022

NARRATIVE

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A copy of a fax cover sheet from the facility to R1's doctor confirms that family members of R1 called 911 to assist R1 from an unwitnessed fall. Interviews and facility records confirm that one of the staff members (S1) who generally has possession of one of the two "after-hours" phone lines was on a FaceTime call with another resident's doctor (and therefore unable to answer the telephone) during the time that 911 responded to the facility to assist R1. Staff are unclear on why the other after-hours phone was not answered.

The facility's pendant alert call records show that on 4/24/22 at 5:41pm, R1 pressed their pendant for assistance. The same records show that a staff member (S2) acknowledge the call over one hour later, but the call was not cleared for over 11 hours. Facility staff charting notes that 911 responded to the facility at approximately 6:35pm, which is almost one hour after R1 initially pressed their call button, and approximately one half hour before the pendant alert logs show that staff even acknowledged the alert on their devices. When LPA Colvin interviewed the Assistant Executive Director (AED) requesting their opinion on how long is an appropriate amount of time for a resident to wait for assistance, the AED declined to provide a specific time frame. LPA Colvin asked the same question of another staff in a leadership position, and was answered with "5 to 8 minutes" or to have staff at least "pop in to see what is needed if they know they are going to take longer". In either case, it is clear that this was not followed as R1 pressed their pendant for assistance at 5:41pm, and was not provided with assistance until 911 responded nearly an hour after R1 initially requested staff help through pressing their call button.

Therefore, based on interviews and record review, the allegation "Staff did not assist resident from fall in a timely manner." is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met.

Due to observations made by LPA Colvin, the facility was cited, and deficiencies noted on LIC 9099 D. An exit interview was conducted where this report and appeal rights were discussed. A copy this report, LIC 9099D, and appeal rights were provided to Assistant Executive Director Lorena Vivar during the exit interview.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 18-AS-20220426111939

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: LAS VILLAS DEL NORTE	FACILITY NUMBER: 374604294
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/29/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/02/2022 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	Additional Personal Rights of Residents in ...Facilities: (a) In addition to the rights listed ...residents...shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers...to meet their needs.	1 2 3 4 5 6 7	Licensee agrees to review staffing needs for facility based on call response times for residents. Licensee to consider contracting with additional staffing agencies to ensure reliable coverage for facility. Licensee may self-certify to LPA Colvin what the results of their review is and what their plan for staffing
	8 9 10 11 12 13 14	This requirement was not met by: Based on record review and interviews, the Licensee did not comply with the above allegation with one resident. On 4/24/22, R1 pressed their call button for help at 5:41pm, but was not provided assistance by staff. 911 respond at 6:35pm. This was an immediate safety risk to R1.	8 9 10 11 12 13 14	moving forward is to essure resident's calls are being responded to in a timely manner. Self- Certtification to be submitted to LPA Colvin by Plan of Correction date of 5/2/22.
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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: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022

LIC9099 (FAS) - (06/04)

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