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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604411
Report Date: 01/24/2024
Date Signed: 01/24/2024 07:17:26 PM


Document Has Been Signed on 01/24/2024 07:17 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:LA MAREA SENIOR LIVINGFACILITY NUMBER:
374604411
ADMINISTRATOR:DARYL ANN C ROBINSONFACILITY TYPE:
740
ADDRESS:5592 EL CAMINO REALTELEPHONE:
(442) 325-3510
CITY:CARLSBADSTATE: CAZIP CODE:
92008
CAPACITY:125CENSUS: 96DATE:
01/24/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Interim Executive Director Becca BlackTIME COMPLETED:
07:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Dang Nguyen and Juliana Barfield conducted an unannounced Case Management - Incident visit. LPAs were welcomed by, identified themselves to, and discussed the purpose of the visit with Interim Executive Director Becca Black.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (it was received on business day 01/22/2024). According to the LIC624: on 01/13/2024, Resident #1 (R1) eloped from the facility (left without staff supervision). [See LIC 811 Confidential Names List for a description of select person identifiers used.] Facility staff located R1 the same day, and returned them to the facility, unharmed.

During today’s visit, LPAs performed a brief facility tour and welfare check on R1, verifying that they were indeed safe. LPAs also collected copies of and reviewed pertinent records and interviewed relevant staff.

According to their latest LIC602 Physician’s Report (dated 07/19/2023), R1 was diagnosed with Dementia and their doctor determined that they were not able to safely leave the facility unassisted. The multiple care appraisals which Licensee performed on R1, since the time of their move in, corroborated these points.

Due to their baseline memory loss, R1 was not able to serve as a reliable historian/interviewee for this case.


[CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: LA MAREA SENIOR LIVING
FACILITY NUMBER: 374604411
VISIT DATE: 01/24/2024
NARRATIVE
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[CONTINUED FROM LIC 809]

Staff interviews unanimously showed: Around midday on 01/13/2024, R1 entered the facility’s lobby and stated to Staff #1 (S1) and Staff #2 (S2) their intent to leave the facility on foot. S1 freely allowed R1 to leave, unescorted, via the front door. S2 witnessed this, had concerns about it, but did not correct/stop S1 from letting R1 leave. S2 subsequently conferred with other staff, who reinforced that R1 could not be out in the community by themselves. Staff then used vehicles to search for R1. S1 subsequently located R1 and returned them to the facility unharmed. During the incident, R1 was unsupervised for about a half hour.

Staff interviews further showed: Following the incident, Licensee conducted an internal investigation which found that the root cause of the incident was “training” (i.e., S1 did not have a clear understanding of R1’s cognitive limitations and whether R1 was allowed to leave the facility unassisted). Licensee’s staff first told R1’s physician and responsible person (RP) of the AWOL incident on 01/17/2024, which was four days after the incident. Licensee did not send a copy of the written incident report to the RP, as was required to be done within seven days. Licensee’s submission of the written incident report to CCLD was also late.

During records review, LPAs observed (and manager interview confirmed) that Licensee did not possess a written Absentee Notification Plan (or equivalent missing resident policy) for C1 or the other residents in care, as was required.

Two (2) deficiencies were cited per California Code of Regulations, Title 22. One (1) deficiency was cited per California Health and Safety Code. (Refer to the attached LIC 809-D pages). Plans of Correction was jointly developed with the licensee.

An exit interview was conducted with Black, to whom a copy of this report, the LIC809-D pages, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 01/24/2024 07:17 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: LA MAREA SENIOR LIVING
FACILITY NUMBER: 374604411

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/23/2024
Section Cited
CCR
87411(a)

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87411 Personnel Requirements – General: “(a) Facility personnel shall at all times be…competent to provide the services necessary to meet resident needs.” This requirement was not met, as evidenced by:
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Per staff interviews: On 01/18/2024, Licensee performed retraining and an elopement response drill for its direct care staff. Licensee agreed to create a reference binder (with photos) to be kept at the front desk, which will help staff differentiate between those residents who can and cannot leave unassisted. Licensee agreed to send LPA proof of the binder completion, by the POC due date.
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Based on records and interviews, the licensee did not ensure facility personnel (S1) was competent in knowledge to provide the services necessary to meet the safety needs of 1 of 96 residents (R1), which posed a potential safety risk to persons in care.
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Type B
02/23/2024
Section Cited
HSC1569.317

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1569.317 Absentee Notification Plan for Missing Residents: “Every residential care facility for the elderly…shall…develop and comply with an absentee notification plan…The plan shall include…a requirement that an administrator of the facility, or his or her designee, inform the resident’s authorized representative when that resident is missing from the facility…and the circumstances in which [they] shall notify local law enforcement.”
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Licensee agreed to write an Absentee Notification Plan/policy meeting the requirements of CA H&S Code 1569.317, and to train all its staff on it. Licensee also agreed to add a copy of said Absentee Notification Plan in the written record of care for every current and future resident. Licensee agreed to E-mail the Plan and the training sign-in sheet to LPA, by the POC due date.
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This requirement was not met, as evidenced by: Based on records and interviews, licensee’s staff did not develop a written absentee notification plan, which posed a potential safety risk to 96 of 96 clients (C1 through Client #96) 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: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 01/24/2024 07:17 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: LA MAREA SENIOR LIVING
FACILITY NUMBER: 374604411

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/23/2024
Section Cited
CCR
87211(a)(1)(D)

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87211 Reporting Requirements: "(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified...(D) Any incident which threatens the welfare, safety or health of any resident."
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During today’s visit, Licensee E-mailed a copy of the LIC624 Incident Report to R1’s responsible person. Licensee agreed to utilize a third-party source to retrain pertinent facility managers on Regulation 87211 Reporting Requirements. Licensee agreed to E-mail LPA the training sign-in sheet, by the POC due date.
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This requirement was not met, as evidenced by: Based on records and interviews, 1 of 96 residents (R1) had an incident which threatened their welfare, safety, or health, and Licensee did not submit a written report of the incident to CCLD and the person responsible for the resident within seven days of incident occurrence. This posed a potential personal rights risk to persons 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: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4