374604454-10-5-2022-08-AS-DPOL-CKQSKT-20221031135717

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604454
Report Date: 10/05/2022
Date Signed: 10/05/2022 04:56:29 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
09/27/2022 and conducted by Evaluator Esther Miller

PUBLIC

COMPLAINT CONTROL NUMBER: 08-AS-20220927151212

FACILITY NAME:	HUNTINGTON MANOR		FACILITY NUMBER:	374604454
ADMINISTRATOR:	DERAFERA, TESS		FACILITY TYPE:	740
ADDRESS:	14755 BUDWIN LN		TELEPHONE:	(619) 625-6886
CITY:	POWAY	STATE: CA	ZIP CODE:	92064
CAPACITY:	21	CENSUS: 19	DATE:	10/05/2022
		UNANNOUNCED	TIME BEGAN:	12:32 PM
MET WITH:	Tess Derafera, Administrator		TIME COMPLETED:	02:44 PM

ALLEGATION(S):

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Unlawful eviction.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Esther Miller conducted an unannounced complaint investigation visit to the facility in order to deliver findings on the above allegation. LPA was granted entry to the facility by Tess Derafera, Administrator, after identifying herself and explaining the reason for the visit.

On September 27, 2022, it was alleged that the facility unlawfully evicted a resident. The Department’s investigation consisted of LPA observations, review of facility and outside source records, and interviews of facility staff and outside sources.

Around September 26, 2022, the facility submitted a 30-day eviction notice to the Department for Resident 1 (R1) due to resident’s failure to follow facility’s written policies. The specific house rule not followed was “Loud music and/or loud televisions are not permitted.” The eviction notice stated that R1 and R1’s family did not tone down the volume of their voice, music, or television after repeated requests to do so.
[Continued on LIC9099-C, page 1 of 2]

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther Miller	TELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022

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 3

Control Number 08-AS-20220927151212

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: 10/05/2022

NARRATIVE

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[Continued from LIC9099, page 2 of 2]

The eviction notice also stated that resident did not provide normal courtesy to staff members, which violated another house rule. The notice detailed a complaint log in which R1 had verbally abused staff. The House Rules of Conduct was signed by R1 and Administrator on August 19, 2022.

Outside source interviews and documents show that R1 was hospitalized on September 19, 2022. R1 was to be discharged on September 24, 2022 and outside sources stated that Administrator Tess Derafera did not allow R1 to return to the facility. Administrator of a separate licensed facility confirmed that R1 moved into their facility on October 4, 2022. Administrator Tess Derafera confirmed that R1’s personal belongings were moved from the facility on October 3, 2022.

LPA arrived at the facility on October 5, 2022 and observed that R1 was not at the premises. LPA also confirmed that R1’s personal belongings were no longer at the facility and R1’s room was empty. Licensee Zayden Chen and Administrator admitted that R1 was not allowed to return to the facility after being discharged from the hospital. Both Licensee and Administrator also admitted that the 30 day notice sent to the Department was not given to R1.

Based on the evidence obtained during the complaint investigation, the allegation that the facility unlawfully evicted a resident is found to be SUBSTANTIATED, as there is a preponderance of evidence to show that the violation occurred. Pursuant to the California Code of Regulations, Title 22, Division 6, deficiency is being cited on the attached LIC9099D and a plan of correction was jointly developed with Administrator. An exit interview was conducted with Administrator; a copy of this report and Licensee's Rights (LIC9058) were provided.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther Miller	TELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 08-AS-20220927151212

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: 10/05/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/28/2022 Section Cited CCR 87224(a)	1 2 3 4 5 6 7	EVICTION PROCEDURES 87224(a) The licensee may evict a resident...Thirty (30) days written notice to the resident is required.... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator agreed to conduct in-service training to adminstrative staff regarding eviction procedures. Administrator agreed to submit signed acknowledament of training by staff by POC date.
	8 9 10 11 12 13 14	Based on observations, interviews, and record reviews, the licensee did not give thirty (30) days written notice to evict in one of nineteen residents which posed a potential personal rights risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther Miller	TELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3