374604455-8-28-2023-08-AS-DPOL-CV8RPK-20230831131205

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604455
Report Date: 08/28/2023
Date Signed: 08/28/2023 06:42:30 PM

Substantiated

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
07/27/2023 and conducted by Evaluator Marisela Garcia-Centeno

COMPLAINT CONTROL NUMBER: 08-AS-20230727122042

FACILITY NAME:	IVY PARK AT OTAY RANCH		FACILITY NUMBER:	374604455
ADMINISTRATOR:	KAPLIOFF, ANGELA		FACILITY TYPE:	740
ADDRESS:	1290 SANTA ROSE DRIVE		TELEPHONE:	(619) 779-7400
CITY:	CHULA VISTA	STATE: CA	ZIP CODE:	91913
CAPACITY:	137	CENSUS: 92	DATE:	08/28/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Executive Director, Calais Angiano		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Staff spoke inappropriately to residents
Staff did not attend to residents’ call buttons in a timely manner

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced visit to deliver investigative findings. LPA met with Executive Director, Calais Angiano, and shared findings.

The Department investigated the above-listed complaint allegations. The investigation consisted of an inspection of the facility, observations, multiple interviews with residents, and staff, and a detailed review of relevant records.

On July 27, 2023, Community Care Licensing (CCL) received a complaint alleging that staff spoke inappropriately to residents. Specific details of when this occurred were not obtained. However, during the investigation, facility management indicated that on July 26, 2023, a staff member reported an incident they witnessed when a care staff member made inappropriate comments to a resident. A second incident was also reported on August 8, 2023, of unprofessional misconduct between two care staff members in the presence of an outside source. (continue at LIC9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno	TELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023

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 4

Control Number 08-AS-20230727122042

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: 08/28/2023

NARRATIVE

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Continue from LIC 9099)

Both incidents were fully investigated by management who concluded the incidents did occur. Management took immediate corrective action by providing performance management to the staff involved. In addition, on July 27 and August 17, 2023, facility management provided two in-service trainings for all care staff on residents' personal rights, customer service, and personnel standards of conduct. Although, during interviews, most of the residents expressed satisfaction with the service being provided by the care staff, there was sufficient evidence to support the allegation that staff spoke inappropriately to residents.

It was also alleged that staff did not attend to residents’ call buttons in a timely manner. During multiple interviews, residents consistently indicated that when they used their call button it took extended periods of time to get assistance from care staff. Some residents indicated they waited longer than one hour and at times even longer before getting the assistance they needed from care staff. A detailed review of some of the residents who raised concerns about the response time confirmed the response times were excessive. A review of the residents' care plans indicated they required assistance with activities of daily living, such as incontinence care, transfers due to limited mobility, and/or water/food service. Other more serious situations reported were residents needing assistance getting up after a fall. None of the residents reported serious injuries from these falls. The residents also indicated, that although not timely, they eventually received the assistance they needed from care staff. A detailed review of three different residents indicated their response times varied from 1 to 2 hours. According to the facility’s standard, the response time should be 15 minutes or less. A detailed review of the Call Button Excessive Response Report (CBERR) for a 2-month period indicated that in June 2023, there were a total of 867 calls that took longer than 15 minutes with an average of 58-minute response time. In July 2023, there were a total of 1,207 calls that took more than 15 minutes with an average response time of 45 minutes. Facility management indicated the CBERR was misleading. Management’s review discovered that some of the service calls were not cleared as complete in the system after care staff had attended to the resident’s needs. However, facility management acknowledged that this was an area of opportunity for improvement and had been providing training to staff to ensure calls were cleared as complete after servicing the resident. In addition, management stated that they identified staffing needs and scheduled staff accordingly to meet this goal.

(Continue at LIC9099C)

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno	TELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20230727122042

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: 08/28/2023

NARRATIVE

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(continue from LIC9099C)

Based on interviews with residents and staff and records review, there was sufficient evidence to support the allegation that staff did not respond to call buttons in a reasonable amount of time to ensure the health and safety of the residents.

The Department has investigated the above-mentioned allegations and has found that there was sufficient evidence to corroborate the allegations. Therefore, these allegations are deemed to be substantiated. A substantiated finding means the allegation is valid because the preponderance of the evidence standard has been met. A Deficiency was cited per Title 22, Division 6, Chapter 8 of the California Code of Regulations and is listed on LIC 9099-D.

A copy of this report, LIC 9099D, along with Licensee/Appeal Rights (LIC 9058 03/22) was provided to Executive Director, Angiano at the end of the visit.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno	TELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 08-AS-20230727122042

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/28/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/28/2023 Section Cited CCR 87468.1	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities Residents shall be accorded dignity in his/her personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Facility management provided additional training on personal rights to all employees. In addition, employee performance corrective actions were properly completed as required by facility internal personnel policies. Plan of correction has been completed. No additional follow-up warranted at this time.
	8 9 10 11 12 13 14	Interviews with staff and residents and records review revealed the licensee did not ensure staff spoke inappropriately to residents in care. This posed potential personal rights risks to residents in care.	8 9 10 11 12 13 14
Type B 08/28/2023 Section Cited CCR 87464(f)(4)	1 2 3 4 5 6 7	87464 Basic Services (f) (4) Basic services shall at a minimum include, personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living. This requirement was not met as evidence by:	1 2 3 4 5 6 7	Facility managment conducted in-service trainings with all staff to ensure call buttons are attended within the standard response time. Staff were also reminded to ensure calls are closed in the system once residents have been serviced.
	8 9 10 11 12 13 14	Based on observations, interviews, and records review, the licensee did not ensure that residents received personal assistance and care as needed on a timely basis to meet the residents’ needs. This posed a potential health risk to residents in care.	8 9 10 11 12 13 14	In addition, staffing levels needs were reassessed to meet residents needs. Plan of correction has been completed. No additional follow-up warranted at this time.

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) -76-2317
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno	TELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023

LIC9099 (FAS) - (06/04)

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