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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604454
Report Date: 08/25/2021
Date Signed: 08/25/2021 05:19:03 PM



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
08/16/2021 and conducted by Evaluator Dawn Segura
COMPLAINT CONTROL NUMBER: 08-AS-20210816141913
FACILITY NAME:HUNTINGTON MANORFACILITY NUMBER:
374604454
ADMINISTRATOR:DERAFERA, TESSFACILITY TYPE:
740
ADDRESS:14755 BUDWIN LNTELEPHONE:
(619) 625-6886
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY:21CENSUS: 14DATE:
08/25/2021
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Tess Derafera, AdministratorTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Hazardous items are accessible to residents.
Licensee did not follow universal precautions.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Dawn Segura conducted an unannounced visit to conduct an investigation into the above listed complaint allegations. LPA was granted entry into the facility and met with Tess Derafera, Administrator, to whom she explained the reason for the visit.

Community Care Licensing (CCL) has investigated the above listed allegations. The investigation consisted of a tour of the facility, review of facility records, and interview of facility staff.

It was alleged that hazardous chemicals and boards with exposed nails are in areas that are accessible to residents. During LPA's tour of the facility property, LPA observed toxic water treatment chemicals left on a table in an area that is open and accessible to residents. LPA further observed boards with protruding exposed nails in surrounding yard areas of the property that are accessible to residents. Although the items were left in areas that are not immediately accessible to residents, the facility houses residents who have a diagnosis of dementia, are ambulatory, and have accessibility to both areas in which the hazardous items
Substantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619)767-2329
LICENSING EVALUATOR NAME: Dawn SeguraTELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021
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 5
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
08/16/2021 and conducted by Evaluator Dawn Segura
COMPLAINT CONTROL NUMBER: 08-AS-20210816141913

FACILITY NAME:HUNTINGTON MANORFACILITY NUMBER:
374604454
ADMINISTRATOR:DERAFERA, TESSFACILITY TYPE:
740
ADDRESS:14755 BUDWIN LNTELEPHONE:
(619) 625-6886
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY:21CENSUS: 14DATE:
08/25/2021
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Tess Derafera, AdministratorTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Licensee does not have an auditory device monitoring exits.
Licensee is not keeping property clear of debris and other materials that present a safety hazard.

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Dawn Segura conducted an unannounced visit to conduct an investigation into the above listed complaint allegations. LPA was granted entry into the facility and met with Tess Derafera, Administrator, to whom she explained the reason for the visit.

Community Care Licensing (CCL) has investigated the above listed allegations. The investigation consisted of a tour of the facility, review of facility records, and interview of facility staff.

It was alleged that the facility did not have auditory devices providing alerts when invidividuals opened facility doors. During today's visit, LPA observed that the facility did not have auditory alerts implemented on entry/exitways. LPA reviewed the records of all residents housed in the facility, and the review revealed that the facility does not currently house residents who have wandering behaviors. Based upon interviews and record review, facility exits are not required to to be monitored by auditory devices at this time.
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619)767-2329
LICENSING EVALUATOR NAME: Dawn SeguraTELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021
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 5
Control Number 08-AS-20210816141913
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: HUNTINGTON MANOR
FACILITY NUMBER: 374604454
VISIT DATE: 08/25/2021
NARRATIVE
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It was also alleged that the back yard area of the facility is full of piles of debris that presents a fire hazard. During today's visit, LPA toured the back yard of the facility and observed that there are tree trunks that had been cut and organized along the rear of the property in preparation for pickup. LPA also observed that the yard had mulch that appeared to have been recently placed across the backyard; however, LPA did not observe debris that had been piled or that presents a safety hazard.

While the above listed allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur; therefore, the allegations are unsubstantiated.

An exit interview was conducted, and Tess Derafera, Administrator, was provided a copy of this report and Licensee Appeal Rights, via electronic mail, after conclusion of the visit. An electronic receipt of confirmation was requested to be sent to LPA upon receipt of the documents.
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619)767-2329
LICENSING EVALUATOR NAME: Dawn SeguraTELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 08-AS-20210816141913
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: HUNTINGTON MANOR
FACILITY NUMBER: 374604454
VISIT DATE: 08/25/2021
NARRATIVE
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were left.

The second allegation is that licensee did not follow universal precautions. It was reported that individuals visited and toured the facility inside and out, but no COVID-19 screening protocols were followed during the visit. During today's visit, upon arrival, LPA was greeted by staff at the entrance of the facility. LPA entered the facility and observed a table at the entryway that housed screening forms, a thermometer, sanitizing wipes, and hand sanitizer. LPA also observed a number of staff in the immediate living area; however, LPA was allowed to enter the facility and proceed beyond the screening area without being screened. Once LPA inquired whether she would be screened, staff then directed LPA to the screening questionnaire and took and recorded LPA's temperature.

Based upon LPA’s observations during today's visit, the above allegations are substantiated. This finding means that the preponderance of the evidence standard has been met and the allegations are valid. Deficiencies are cited in accordance with California Code of Regulations, Title 22, Division 6, Chapter 8 and noted on the attached LIC 9099-D.

An exit interview was conducted with Tess Derafera, Administrator, and the administrator was provided a copy of this report and Licensee Appeal Rights, via electronic mail, after conclusion of the visit. An electronic receipt of confirmation was requested to be sent to LPA upon receipt of the documents.

Note: LPA was away from the facility property from 1:15 - 3:15 PM
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619)767-2329
LICENSING EVALUATOR NAME: Dawn SeguraTELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 08-AS-20210816141913
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: HUNTINGTON MANOR
FACILITY NUMBER: 374604454
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/03/2021
Section Cited
CCR
87705(f)(2)
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Care of Persons with Dementia. (f) The following shall be stored inaccessible to residents with dementia: (2) . . .toxic substances such as certain plants, gardening supplies, cleaning supplies, and disinfectants. This requirement was not met as evidenced by:
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During the visit, the toxic chemicals were removed from the table and stored in a locked cabinet on the facility property and made inaccessible to residents. The boards with protruding nails were disposed of in the dumpster that is inaccessible to residents.
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Based on record review and LPA's observation, licensee did not ensure that toxic substances and hazardous items were inaccessible to residents with dementia. This posed a potential safety risk to 3 of 14 residents in care who have a diagnosis of dementia and are ambulatory.
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Administrator offered to provide in-service training on proper storage of toxic chemicals and safety awareness to all staff on 9/1/2021. Administrator offered to provide proof of training to Community Care Licensing by 9/3/2021.
Type B
09/03/2021
Section Cited
CCR
87468.1(a)(2)
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Personal Rights of Residents in All Facilities. (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by:
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Administrator offered to conduct in-service training on 9/1/2021 to address COVID-19 screening protocols with all staff. Administrator offered to provide proof of training to Community Care Licensing by 9/3/2021.
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Based on LPA's observation, licensee did not provide residents with safe and healthful accommodations. This posed a potential health risk to 14 of 14 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: Rebecca HedgecockTELEPHONE: (619)767-2329
LICENSING EVALUATOR NAME: Dawn SeguraTELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5