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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604454
Report Date: 02/05/2024
Date Signed: 02/06/2024 02:25:38 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
01/09/2024 and conducted by Evaluator Natasha Persaud
COMPLAINT CONTROL NUMBER: 08-AS-20240109081821
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: 21DATE:
02/05/2024
UNANNOUNCEDTIME BEGAN:
01:31 PM
MET WITH:Administrator, Tess DeraferaTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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-Staff did not address resident's medical condition timely
-Staff did not ensure resident's call pendant was working
-Staff did not address bed bug infestation
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit to conclude the complaint investigation regarding the above-mentioned allegation. LPA met with Administrator, Tess Derafera.

During the investigation, the facility was briefly toured, records reviewed, and interviews with staff, residents, and outside sources. It was alleged that staff did not address Resident #1’s (R1) medical condition timely. R1’s Physician’s Report dated 09/26/22 indicated R1 was unable to handle their activities of daily living (ADL) such as toileting, showering, and dressing/grooming. R1’s Resident Appraisal dated 02/22/23 indicated R1 required full assistance with ADL's, had right side paralysis and was not mentally stable. The appraisal also stated R1 was verbally abusive with a tendency to become violent. The facility provided the following services to R1, bathing, grooming/dressing, help moving about the facility, eating, medications, and toileting as R1 was incontinent of both bowel and bladder. On 01/06/24, R1’s responsible party observed an infection located on R1’s chest area. The responsible party called 911 and R1 was transported to the hospital for evaluation. Continued on an LIC 9099C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2024
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
Control Number 08-AS-20240109081821
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: 02/05/2024
NARRATIVE
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The hospital evaluated that R1 had mild erythema of an old chest scar that seemed to be very mild cellulitis. Also, R1 was diagnosed with a diffuse nonspecific rash that could be bed bugs versus nonspecific dermatitis. R1 was prescribed medications for the itch/bites. Staff interviews stated they provided R1 with dressing and showers but did not observe any bites on R1 on 01/05/24, 01/06/24, or 01/07/24. However, staff reported R1 was constantly itching and scratching their body. The administrator did not observe the bites or was notified by staff, as they were out on vacation during that period.

It was also alleged staff did not address bed bug infestation. On 01/06/24, when R1 was transported to the hospital for a possible chest infection, it was identified that R1 was covered in bug bites. R1’s responsible party reported the bites to the licensee. On 01/09/24, R1’s responsible party and an outside source witnessed bed bugs on R1’s bed. On 01/09/24 R1’s mattress and recliner were disposed of. The staff stated they used Clorox wipes to wipe down R1’s furniture and washed the clothing R1 was wearing in bleach. Staff confirmed R1’s clothing in their drawers was not bagged up or washed in heat. Staff were not aware of universal precautions regarding bed bugs. The licensee stated a professional pest control company came to the facility on 01/10/24 and did not observe bed bugs. The pest control company documented on 01/10/24, no live activity or evidence of activity was seen; mattresses and other bed clothing were already discarded, and inspected area cleaned out, before visual inspection. The licensee’s interview revealed he did not witness bed bugs. However, R1’s items were already disposed of prior to licensee’s inspection on 01/10/24.

It was also alleged the staff did not ensure R1’s call pendant was working. The administrator stated R1 throws their call button, and it breaks. R1 was given three (3) call buttons and destroyed all of them. Staff interviews indicated R1’s mental condition inhibits R1 from using the call button. Outside source interviews revealed when R1 had a call button but it did not work, as the outside source would push the button to try and alert staff but there was no response. R1’s responsible party also attempted to activate the call button on numerous occasions and did not work to alert staff. The administrator was not aware the call button was not operating, as it was not brought to her attention. It’s possible the button was broken due to R1 throwing it. However, staff did not ensure R1 was afforded the call button for assistance. Staff mentioned they observed the call button hanging from R1’s nightstand but also not aware the button was not working. Staff also stated they do not check or monitor the call buttons for residents. The facility is required to have a signal system as outlined in Title 22 Regulation, which shall operate from each resident's living unit. On 01/17/24, LPA toured R1’s bedroom and did not observe a call button. Continued on an LIC 9099C.

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 08-AS-20240109081821
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: 02/05/2024
NARRATIVE
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Further staff interviews revealed the last time they observed the call button was approximately one (1) week prior to LPAs visit. Staff did not alert the administrator that R1’s call button was not working or present in their room.

Based on LPA’s observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 8 are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Administrator, Tess Derafera whose signature below confirms receipt of these rights.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 08-AS-20240109081821
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: 02/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/04/2024
Section Cited
CCR
87466
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Observation of the Resident. The licensee shall ensure...residents are regularly observed for changes in physical...when such observation reveals unmet needs. When changes...are observed...the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by:
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Administrator stated she will conduct In-Service training regarding observations of the residents and reporting observations. Training is due by POC due date.
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Based on interviews and records, the licensee did not ensure 1 out of 21 [R1] residents were observed for a medical condition requiring medical treatment, which poses a potential health and safety risk to residents in care.
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Type B
03/04/2024
Section Cited
CCR
87303(i)(2)
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Maintenance and Operation. Facilities shall have signal systems which shall meet the following criteria: Facilities having more than one wing, floor or building shall be permitted to have a separate system in each, provided each meets the above criteria. This requirement is not met as evidenced by:
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Administrator stated she will implement a new policy to ensure call buttons are operable and by having staff check/test the call buttons on an ongoing basis. The administrator also stated she will provide an In-Service training to staff regarding the call buttons. Proof of new policy and training are due by POC date.
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Based on observations and interviews, the licensee did not ensure 1 out of 21 [R1] residents call buttons were operable, which poses a potential health and safety risk to 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: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 08-AS-20240109081821
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: 02/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/04/2024
Section Cited
CCR
87468.1(a)(2)
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Personal Rights of Residents in All Facilities. To be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment. This requirement is not met as evidenced by:
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Administrator stated she will conduct In-Service training on universal precautions regarding bed bugs and provide proof of training by POC due date.
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Based on interviews, the licensee did not ensure 1 out of 21 [R1] residents were afforded healthful accommodations due to not following universal precautions for bed bug infestation, which poses a potential health and safety risk to resident 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: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2024
LIC9099 (FAS) - (06/04)
Page: 5 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
01/09/2024 and conducted by Evaluator Natasha Persaud
COMPLAINT CONTROL NUMBER: 08-AS-20240109081821

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: 21DATE:
02/05/2024
UNANNOUNCEDTIME BEGAN:
01:31 PM
MET WITH:Administrator, Tess DeraferaTIME COMPLETED:
03:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not meet resident's incontinence care needs
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit to conclude the complaint investigation regarding the above-mentioned allegation. LPA met with Administrator, Tess Derafera.

During the investigation, the facility was briefly toured, records reviewed, and interviews with staff, residents, and outside sources. It was alleged that staff did not meet Resident #1’s (R1) incontinence care needs. It was reported once R1 had a bowel movement they smeared their feces everywhere, due to their medical condition. R1’s Physician’s Report dated 09/26/22 indicated R1 was unable to handle their activities of daily living (ADL) such as toileting, showering, and dressing/grooming. The Physician’s Report also stated R1 was continent of bowel and bladder. The report had conflicting information. R1’s Resident Appraisal dated 02/22/23 indicated R1 required full assistance with ADL's, had right side paralysis and was not mentally stable. The appraisal also stated R1 was verbally abusive with a tendency to become violent. Continued on an LIC 9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 08-AS-20240109081821
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: 02/05/2024
NARRATIVE
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The facility provided the following services to R1, bathing, grooming/dressing, help moving about the facility, eating, medications, and toileting as R1 was incontinent of both bowel and bladder. Staff interviews confirmed R1 was verbally abusive and violent, causing injury to staff.

On 01/08/24, R1’s family member observed R1 calling for help as they already had bowel movement and smeared feces on their bed, and walls. R1 was identified with a medical condition that had R1 reach into their diaper after defecating and used their hand to smear the feces on themselves and items. Staff interviews confirmed R1 will reach into their diaper and smear their feces. Further staff interviews revealed R1 had multiple bowel movements a day, between four (4) to five (5) times a day. R1 did not have a regular bowl movement schedule, therefore, staff were unable to gauge when to the bowl movement and smearing of feces would occur.

Staff stated they checked on R1 every 30 minutes. Additional staff interviews revealed they checked on R1 every two (2) hours. The administrator explained they do not provide one on one care to residents. Therefore, they cannot always know when R1 was going to have a bowel movement tin order to get to R1 prior to R1 smearing feces. Staff confirmed once observing R1 with feces, R1 was changed and showered more than their allotted shower days, which was twice a week. Staff confirmed R1 would typically receive four (4) or more showers a week due to wanting to ensure R1 was kept clean.

During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegation. The allegation was deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Administrator, Tess Derafera whose signature below confirms receipt of these rights.

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 7