374604336-8-28-2023-08-AS-SJAB-CV7TQY-20230830145645

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604336
Report Date: 08/28/2023
Date Signed: 08/28/2023 01:47:43 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
08/09/2022 and conducted by Evaluator Amy Domingo

COMPLAINT CONTROL NUMBER: 08-AS-20220809090925

FACILITY NAME:	COMPASSIONATE CARE FOR SENIORS 1		FACILITY NUMBER:	374604336
ADMINISTRATOR:	BACINSKI, MAJA		FACILITY TYPE:	740
ADDRESS:	8100 BINNEY PL.		TELEPHONE:	(619) 303-0670
CITY:	LA MESA	STATE: CA	ZIP CODE:	91942
CAPACITY:	6	CENSUS: 6	DATE:	08/28/2023
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Maja Bacinski Administrator		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Resident sustained pressure injury while in care.
Resident is left in bed for an extended period of time.
Staff do not assist resident when needed.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Amy Domingo, conducted an unannounced visit to deliver findings to the above mentioned complaint allegations. LPA Domingo identified herself and discussed the purpose of the visit with Administrator Maja Bacinski.

The Department’s investigation consisted of record reviews, interviews with staff and outside sources.

It was alleged that Resident 1 (R1) sustained pressure injury while in care. (See LIC811 list of confidential list of identification). Interview with Outside Source (OS1) stated that R1 had pressure injuries on the lower extremities. OS1 stated that there were pictures of the pressure injuries. On 08/15/2022 LPA requested information verifying pressure injuries of R1.

[Continue on LIC9099C]

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Amy Domingo	TELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023

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-20220809090925

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: COMPASSIONATE CARE FOR SENIORS 1	FACILITY NUMBER: 374604336
	VISIT DATE: 08/28/2023

NARRATIVE

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[Continued from LIC9099]

On 10/13/2022 LPA reached out to OS1 requesting the information regarding R1. On 11/08/2022 LPA Domingo reached out via e mail requesting the information regarding R1. The requested information was not made available to the LPA after several attempts to obtain the information. Based on the review of R1's records, there was no documentation of pressure injuries. Based on staff interviews there was no pressure injuries on R1.

It was alleged that the Resident 1 (R1) was left in bed for an extended period of time.
Interview with Outside Source (OS2) stated that there are no concerns regarding residents left in bed for an extended period of time. Staff 1 (S1) provided training documentation regarding caring for the elderly of all the staff that was working during the time of the complaint. Based on the facility schedule there were staff providing care throughout a 24 hour period.

It was alleged that Staff do not assist resident when needed. Interview with R1 and Resident 2 (R2) did not provide any evidence of staff not assisting residents when needed. R1 and R2 collectively stated that all the staff provide good care and attention to their needs. Outside Source 3 (SO3) was interviewed and there were no concerns regarding staff assisting the residents when needed. Outside Source 4 (OS4) confirmed during an interview that there are no concerns regarding resident care and meeting the resident's needs.

The Department has investigated the above mentioned allegation and the preponderance of the evidence standard has not been met. Therefore, the allegation is unsubstantiated.

A copy of this report along with Licensee Appeal Rights (LIC 9058 03/22) was provided to the Licensee and the signature on this form confirms receipt of these rights.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Amy Domingo	TELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023

LIC9099 (FAS) - (06/04)

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