374604305-3-22-2024-18-AS-IESA-D3WA5L-20240331235520

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604305
Report Date: 03/22/2024
Date Signed: 03/22/2024 11:51:36 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/22/2024 and conducted by Evaluator Liliana Silveira

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20240322110416

FACILITY NAME:	BLUE SKIES OF SAN MARCOS		FACILITY NUMBER:	374604305
ADMINISTRATOR:	AQUINO, RODELIO D.		FACILITY TYPE:	740
ADDRESS:	1119 VIA VERA CRUZ		TELEPHONE:	(760) 736-4099
CITY:	SAN MARCOS	STATE: CA	ZIP CODE:	92078
CAPACITY:	6	CENSUS: 5	DATE:	03/22/2024
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Caregiver Jean Paul Reyes		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Lack of care resulting in serious injury.
Staff did not provide incontinence care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Liliana Silveira conducted an unannounced complaint investigation visit. LPA Silveira introduced themselves, met with Caregiver Jean Paul Reyes and disclosed the purpose of the visit. The purpose of the visit was to deliver findings for the above-mentioned allegations.

The Department’s investigation consisted of interviews with staff, outside sources and a records review. It was alleged that Resident #1 (R1) suffered a fractured vertebrae while in care in October 2021. It was also alleged that R1 was left in soiled clothing for extended periods of time during this same timeframe.

A review of a doctor’s report dated 04/26/21 revealed that R1 was diagnosed with Alzheimer’s disease. Based on the doctor’s evaluation, the report indicated that R1 was able to communicate their needs. A review of medical and facility records also demonstrated that R1 was not considered a fall risk. [CONTINUED ON LIC 9099-C]

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Liliana Silveira	TELEPHONE: (619) 314-0756
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024

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 18-AS-20240322110416

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: BLUE SKIES OF SAN MARCOS	FACILITY NUMBER: 374604305
	VISIT DATE: 03/22/2024

NARRATIVE

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[CONTINUED FROM LIC 9099] An interview with Staff #1 (S1) revealed that R1 was found lying on the floor near their bed the evening of 10/20/21. R1 was assisted by S1 back to bed. S1 stated that R1 did not express that they were in pain. S1 stated that R1 did not complain about back pain until the morning of 10/23/21.

On 10/23/21 R1 was sent to a hospital Emergency Room due to back pain. Medical Records from that hospital visit on 10/23/21 indicated that R1 was diagnosed with a vertebral body fracture with a subacute injury. A Department interview with R1’s PCP revealed that R1 had a history of back pain due to a medical condition, and had a higher risk of bone fracture due to thinning of the bone. The PCP also stated that a subacute injury indicated that the injury could have happened several days ago or up to several months ago. R1’s PCP stated that it is possible that R1 fractured their vertebrae previously at an unknown date and time and may have aggravated the injury on 10/20/21.

A Department interview with an outside source revealed that they spoke to the Emergency Room (ER) doctor who attended R1 on 10/23/21. The ER doctor indicated that R1 had a fractured vertebrae, but it was not determined to be a new injury. The ER doctor also indicated that R1 was diagnosed with a medical condition that causes brittle bones; the fracture could have occurred from R1 just sitting down. The outside source also indicated that they did not believe that R1 had been mistreated or abused by facility staff. The outside source stated that they had visited R1 at the facility on various occasions, and never observed any inappropriate behavior by staff towards R1 or other residents.

The outside source also stated that R1 was always found to be clean during facility visits and they do not believe that there were any issues with R1 being left for extended periods of time in soiled clothing. The department attempted to interview other relevant witnesses to no avail. Facility staff denied leaving residents in soiled clothing for extended periods of time. A review of facility and medical records also did not reveal any health issues or care issues related to a lack of incontinence care.

Due to a lack of corroborating evidence, the allegations that lack of care resulted in serious injury to a resident and that staff did not provide incontinence care are unsubstantiated. This finding means that although the allegations may have happened or could be valid, there is not a preponderance of evidence to prove that the alleged violations occurred. [CONTINUED ON LIC 9099-C]

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Liliana Silveira	TELEPHONE: (619) 314-0756
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20240322110416

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: BLUE SKIES OF SAN MARCOS	FACILITY NUMBER: 374604305
	VISIT DATE: 03/22/2024

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 LIC 9099-C] LPA Silveira conducted an exit interview with Arlan Acosta. At the time of the exit interview Arlan was provided with a copy of the Complaint Investigation Report (LIC9099) and Licensee Rights (LIC9058 01-2016). The signature on this report acknowledges receipt of the rights.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Liliana Silveira	TELEPHONE: (619) 314-0756
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024

LIC9099 (FAS) - (06/04)

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