374604455-2-12-2024-08-AS-SJAB-D2WP5V-20240229100121

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604455
Report Date: 02/12/2024
Date Signed: 02/12/2024 12:56:04 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
02/07/2024 and conducted by Evaluator Ramon Serrano

COMPLAINT CONTROL NUMBER: 08-AS-20240207120418

FACILITY NAME:	IVY PARK AT OTAY RANCH		FACILITY NUMBER:	374604455
ADMINISTRATOR:	CALAIS ANGUIANO		FACILITY TYPE:	740
ADDRESS:	1290 SANTA ROSE DRIVE		TELEPHONE:	(619) 779-7400
CITY:	CHULA VISTA	STATE: CA	ZIP CODE:	91913
CAPACITY:	137	CENSUS: 109	DATE:	02/12/2024
		UNANNOUNCED	TIME BEGAN:	09:37 AM
MET WITH:	Calais Anguiano		TIME COMPLETED:	01:09 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident sustained injuries due to lack of care from staff

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Ramon Serrano, conducted an unannounced Complaint Visit. LPA introduced himself and discussed the purpose of the visit with Executive Director Calais Anguiano.

Community Care Licensing (CCL) has investigated the above allegation. The investigation consisted of records review and interviews with facility staff and outside source.

It was reported to CCL that Resident 1 (R1)(an LIC 811 Confidential Names List was provided to the facility representative to identify the resident) had an unwitnessed fall and sustained bruising. It was alleged that R1 sustained those injuries due to lack of care from staff. Records review revealed R1 had an unwitnessed fall on February 4, 2024. Hospital discharge records revealed no new findings or new medications. Facility staff notated on February 5, 2024 at approximately 2pm; R1 was confused and crying and a "PRN" was given to R1. R1 refused to eat dinner that same day and was "very confused." Facility staff notified R1's POA and Physician.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Ramon Serrano	TELEPHONE: (619) 458-2583
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2024

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 2

Control Number 08-AS-20240207120418

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: IVY PARK AT OTAY RANCH	FACILITY NUMBER: 374604455
	VISIT DATE: 02/12/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Records review indicate R1 was monitored by facility staff daily and on February 6, 2024 facility staff notated that R1 ate well and took all of R1's medications with no issues to report. On the same day, R1 was found on R1's bathroom floor and was transported to the hospital.

Interview with Memory Care Director(MCD) revealed they are in close contact with R1's responsible party due to the recent changes R1's Primary Care Physician had made. MCD stated that most of R1's medication's were changed, as a result, R1 has been much more confused and agitated. MCD stated that R1 has also been falling more. MCD stated that R1 returned from the hospital both times with no new orders. R1 was given a walker due to R1 being "more unstable." MCD stated that R1's responsible party is working directly with R1's physician to the "fix" R1's medications.

LPA interviewed R1's responsible party (RP) RP stated that the hospital staff advised RP of bruising that was found on R1's body. RP stated that R1 was transferred to a different hospital after the initial hospital R1 was sent to. RP stated that R1 was given a suction catheter and a full catheter at both hospitals. RP stated that R1 was seen pulling at the catheter tubes. RP advised hospital doctor of the various catheters that R1 was given for over three days and questioned if that could have been the cause of the bruising. RP stated that the hospital doctor stated that "it made sense" and agreed that the catheters could have been the cause of the bruising that was found on R1.

Interview with Executive Director (ED) revealed R1 often gets confused and needs to be redirected and as a result constant staff attention is paid to R1. ED stated that facility staff follow R1's care plan which states that R1 needs constant observation. ED stated that although the staff to resident ratio is not 1:1, the facility staff are still able to monitor R1 closely. ED further stated that often times R1's behaviors or refusals are the cause of R1's incidents and facility staff are constantly trying to figure out ways to better assist R1.

Based upon the foregoing, the above listed allegation is unsubstantiated. This finding means that the preponderance of the evidence standard has not been met and the allegation is not valid.

An exit interview was conducted with Calais Anguiano. A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to Calais Anguiano whose signature below verifies receipt of these rights.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Ramon Serrano	TELEPHONE: (619) 458-2583
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2