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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604306
Report Date: 04/27/2022
Date Signed: 04/27/2022 04:49:47 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, 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
09/11/2020 and conducted by Evaluator Marisela Garcia-Centeno
COMPLAINT CONTROL NUMBER: 08-AS-20200911093038
FACILITY NAME:DALEINA'S HOME CAREFACILITY NUMBER:
374604306
ADMINISTRATOR:CARMONA, CARINA B.FACILITY TYPE:
740
ADDRESS:815 ARCADIA PLACETELEPHONE:
(619) 475-3561
CITY:NATIONAL CITYSTATE: CAZIP CODE:
91950
CAPACITY:6CENSUS: 6DATE:
04/27/2022
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Administrator, Carina Carmona TIME COMPLETED:
02:10 PM
ALLEGATION(S):
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Facility staff did not seek timely medical care
Licensee did not follow reporting requirements
Licensee did not safeguard resident’s personal property
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced visit at the facility to deliver findings for a complaint investigation. LPA identified herself and discussed the purpose of the visit with Administrator, Carina Carmona.

The Department’s investigation consisted of multiple interviews with staff, outside sources and records review, including medical records and other relevant documents pertinent to this investigation.

On September 11, 2020, it was alleged that staff did not seek timely (emergent) medical care for Resident (R1) after a fall. Administrator was provided with Confidential Names Form (LIC 811) in order to identify R1. According to facility records and other relevant records such as admissions appraisal and physicians’ reports, R1 was a 92-year-old resident diagnosed with dementia. R1 was ambulatory and used to walk inside the facility independently. On August 1, 2020, R1 had an unwitnessed fall which resulted in R1 sustaining a fractured left knee and bruising and swelling on their head and eye. Facility staff, after observing R1 for injuries, did not call 911 nor transport R1 to the hospital for further medical assessment or care. In addition, there was swelling to R1 left knee the next day and up to August 27, 2020, when a doctor’s appointment was finally made for R1.

Continued on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Marisela Garcia-CentenoTELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2022
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 7
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
09/11/2020 and conducted by Evaluator Marisela Garcia-Centeno
COMPLAINT CONTROL NUMBER: 08-AS-20200911093038

FACILITY NAME:DALEINA'S HOME CAREFACILITY NUMBER:
374604306
ADMINISTRATOR:CARMONA, CARINA B.FACILITY TYPE:
740
ADDRESS:815 ARCADIA PLACETELEPHONE:
(619) 475-3561
CITY:NATIONAL CITYSTATE: CAZIP CODE:
91950
CAPACITY:6CENSUS: 6DATE:
04/27/2022
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Administrator, Carina Carmona TIME COMPLETED:
02:10 PM
ALLEGATION(S):
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9
Lack of supervision resulting in injuries
Facility staff did not administer medication according to physician’s orders
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced visit at the facility to deliver findings for a complaint investigation. LPA identified herself and discussed the purpose of the visit with Administrator, Carina Carmona.

The Department’s investigation consisted of multiple interviews with staff, outside sources and records review, including medical records and other relevant documents pertinent to this investigation.

On September 11, 2020, it was alleged that Resident (R1) sustained injuries due to lack of supervision. Administrator was provided with Confidential Names Form (LIC 811) in order to identify R1. According to facility records and other relevant records such as admissions appraisal and physicians’ reports, R1 was a 92-year-old resident diagnosed with dementia. R1 was ambulatory and used to walk inside the facility independently. On August 1, 2020, after living at the facility for approximately two (2) years, R1 had an unwitnessed fall which resulted in R1 sustaining a fractured left knee and bruising and swelling on their head and eye.

Continued on LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Marisela Garcia-CentenoTELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 08-AS-20200911093038
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: DALEINA'S HOME CARE
FACILITY NUMBER: 374604306
VISIT DATE: 04/27/2022
NARRATIVE
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Continued from LIC9099A

When the fall occurred, facility staff were nearby and heard the fall and immediately came to assist R1 by providing first aid. R1 was not able to tell staff the cause of the fall due to having dementia. However, according to staff, R1 was able to get up and did not complaint of any pain. According to interviews with staff and outside parties, R1 did not have a history of falls during the two (2) years they had lived at the facility nor did R1 have a history of falls prior to moving into the facility. Staff indicated that R1 enjoyed walking inside the facility and was able to walk around without a walker or a cane with no problems. Based on the information gathered during the interviews conducted with staff and outside parties and the information obtained from the records reviewed, there was insufficient evidence to indicate that facility staff were neglectful in the supervision of R1 that could have contributed to R1’s fall.

It was also alleged that facility staff did not administer medication according to physician's orders. Interviews conducted with staff and outside parties revealed that R1 was taking medication for high blood pressure. During interviews, staff consistently indicated that all medications including the medication to treat high blood pressure were administered to R1 according to physicians’ orders. All medications including the high blood pressure medication were delivered by the pharmacy every month, and the high blood pressure medication was in the “bubble packs” which made it very easy not to miss any doses. Review of R1’s Medication Administration Records indicated that all medications were administered as prescribed, Specifically, staff indicated that because R1 had a history of high blood pressure, they were diligent about giving the medication to R1 every morning as prescribed.

The Department has investigated the above-mentioned allegations and has found that based upon interviews and record reviews, there is insufficient evidence to corroborate the allegations. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, these allegations are deemed to be unsubstantiated.

An exit interview was conducted with Administrator, Carina Carmona. A copy of this report, and Licensee Appeal Rights (9058 01/16) were provided to Administrator after the conclusion of the visit.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Marisela Garcia-CentenoTELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 08-AS-20200911093038
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: DALEINA'S HOME CARE
FACILITY NUMBER: 374604306
VISIT DATE: 04/27/2022
NARRATIVE
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continued from LIC9099

Administrator indicated that they attempted to call to make an appointment with the primary care physician, but when the doctor’s office did not return the call for several weeks, facility staff still did not take R1 to see a doctor. The Administrator said that the reason they did not take R1 to the doctor was because they did not want to expose R1 or the other residents living in the facility to being infected with Covid-19. However, even after they observed the knee getting more swollen day-by-day, the licensee still did not take R1 to see a doctor. According to facility staff, they waited almost four (4) weeks to take R1 to see a doctor. When medical attention was finally provided, it was discovered that R1 had suffered a patellar (knee) fracture that required surgery. Based on the information gathered during the investigation, the Department was able to obtain sufficient evidence to support the allegation that facility staff did not seek timely (emergent) medical attention for R1. According to regulation, the gravity of the injuries R1 sustained warranted the licensee to provide medical attention to include arrangement for and/or provision of transportation to the nearest available medical provider.

It was also alleged that staff did not follow reporting requirements when R1 sustained a serious injury due to a fall. During interviews with facility staff, it was indicated that when R1 had the fall on August 1, 2020, sustaining a fractured knee and bruising to the head and eye, facility staff did not report the incident to the Department as required. According to regulation, the licensee shall furnish to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events, including incidents that result in injury. The Administrator admitted they were aware of the regulation but did not have a chance to submit the report as required.

It was also alleged that facility staff did not safeguard R1’s personal property. According to interviews with facility staff and outside parties, when R1 moved into the facility they brought a suitcase full of clothes. According to the Administrator, the suitcase was disposed of because it was broken and unusable. However, R1’s responsible party claimed the suitcase was in new condition and in working order and they did not give permission for staff to dispose of the suitcase. Licensee may not dispose of resident’s personal belongings without obtaining prior consent.

Continued on LIC9099C
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Marisela Garcia-CentenoTELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 08-AS-20200911093038
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: DALEINA'S HOME CARE
FACILITY NUMBER: 374604306
VISIT DATE: 04/27/2022
NARRATIVE
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Continued from LIC9099C

The Department has investigated the above-mentioned allegations and has found that based upon interviews and record reviews, there is sufficient evidence to corroborate the allegations. Therefore, these allegations are deemed to be substantiated. A substantiated finding means the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies were cited per Title 22, Division 6, Chapter 8 of the California Code of Regulations and are listed on LIC 9099-D. A plan of corrections was developed with Administrator, Carina Carmona.

An exit interview was conducted with Administrator, Carina Carmona. A copy of this report, and Licensee Appeal Rights (9058 01/16) were provided to Administrator after the conclusion of the visit.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Marisela Garcia-CentenoTELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 08-AS-20200911093038
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: DALEINA'S HOME CARE
FACILITY NUMBER: 374604306
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/26/2022
Section Cited
CCR
80075(g)
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87465(g) Incidental Medical and Dental Care
The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health. This requirement was not met as evidenced by:
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Administrator agreed to conduct in service training by an independent provider for all staff facility on how to provide incidental medical care to residents in care by 30 days of POC date. Documentation of trainings conducted will be included in staff personnel records and provided to CCL by POC date.
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Based on the information gathered during the investigation, the Department was able to obtain sufficient evidence to support the allegation that facility staff did not seek emergent medical attention for 1 of 6 residents. This posed an immediate health risk to 1 of 6 residents in care.
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Type B
04/26/2022
Section Cited
CCR
87211(a)(1)(B)
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87211(a)(1)(B) Reporting Requirements
A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of any serious injury ……. occurring while the resident is under facility supervision. This requirement was not met evidenced by:
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Administrator agreed to conduct in service training by an independent provider for all staff facility on reporting requirements by 30 days of POC date. Documentation of trainings conducted will be included in staff personnel records and provided to CCL by POC date.
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Based on interviews conducted it was indicated that facility staff did not report the incident to the Department as required when 1 of 6 residents sustained an injury. This posed an immediate health risk to 1 of 6 residents 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: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Marisela Garcia-CentenoTELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 08-AS-20200911093038
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: DALEINA'S HOME CARE
FACILITY NUMBER: 374604306
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/26/2022
Section Cited
CCR
87468.1(a)(12)
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87468.1(a)(12) Personal Rights of Residents in All Facilities.
Residents in all residential care facilities for the elderly shall have...... the following personal rights: To wear their own clothes; to keep and use their own personal possessions. This requirement was not met evidenced by:
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Administrator agreed to replace resident's property at its current value. In addition, Administrator agreed to conduct in service training by an independent provider to all staff facility on the requirements to safeguard residents personal property by 30 days of POC. date. Documentation of trainings conducted will be included in staff personnel records and provided to CCL by POC date.
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Based on interviews with facility staff and outside parties, Resident (R1) was not allowed to keep personal possession (suitcase)…this posed a potential personal rights risk to 1 of 6 residents in care.
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Administrator agreed to provide proof of purchase or proof of payment for the personal property replaced by POC date.
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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: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Marisela Garcia-CentenoTELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 7