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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604475
Report Date: 07/19/2022
Date Signed: 07/19/2022 12:46:52 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/11/2022 and conducted by Evaluator Crystal Colvin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220711091001
FACILITY NAME:VILLA BERNARDOFACILITY NUMBER:
374604475
ADMINISTRATOR:ANDERSON-CARTER, DAWNFACILITY TYPE:
740
ADDRESS:2960 BERNARDO AVE.TELEPHONE:
(858) 209-6618
CITY:ESCONDIDOSTATE: CAZIP CODE:
92029
CAPACITY:10CENSUS: 8DATE:
07/19/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Yessenia Rebolledo - Facility Director/AdministratorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff will not accept resident back at facility

Facility did not retain resident's records
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced in order to initiate an investigation of a complaint with the above allegation(s). LPA identified herself and discussed the purpose of the visit and the elements of the allegation(s) with Facility Director Yessenia Rebolledo. Below is a summary of the complaint investigation findings:

Regarding allegation "Staff will not accept resident back at facility": LPA Colvin conducted interviews with staff and witnesses as well as reviewed the file for previous resident (R1). LPA Colvin observed that the facility issued a 90-day eviction notice to R1 and R1's responisbile party on 7/2/22, which cited that the facility was unable to meet R1's care needs. On 7/4/22, R1 was taken to the hospital for a psychiatric hold due to manic behaviors. According to interviews condcuted, on 7/7/22, when R1 was ready to be discharge, the facility refused to acccept R1 back, which Director/Administrator Yessenia Rebolledo confirmed with LPA Colvin. Administrator stated that R1's behaviors were becoming too much for the facility to handle. Therefore, due interviews conducted, the allegation "Staff will not accept resident back at facility" is SUBSTANTIATED.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022
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 18-AS-20220711091001
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: VILLA BERNARDO
FACILITY NUMBER: 374604475
VISIT DATE: 07/19/2022
NARRATIVE
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Regarding allegation "Facility did not retain resident's records": This allegation pertains to the facility not retaining R1's Physician's Report (LIC602), which was provided to the facility upon R1's admission. This document was requested from the facility for the purpose of obtaining documents needed to find R1 new placement. During today's inspection, LPA Colvin observed that there is no LIC602 in R1's file at the facility. When asked about the missing document, Administrator confirmed that they do not have the document as it was provided to the emergency response (PERT) team when R1 was being taken away on a psychiatric hold, and that the facility never received this document back. Therefore, due to interviews and record review, the allegation "Facility did not retain resident's records" is SUBSTANTIATED.

A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met.

Due to observations made by LPA Colvin, the facility was cited, and deficiencies noted on LIC 9099 D. An exit interview was conducted where this report and appeal rights were discussed. A copy this report, LIC 9099D, and appeal rights were provided to Facility Director Yessenia Rebolledo during the exit interview.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20220711091001
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: VILLA BERNARDO
FACILITY NUMBER: 374604475
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/20/2022
Section Cited
CCR
87468.2(a)(20)
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Additional...Rights of Residents in...Facilities: (a) In addition to the rights listed...residents ...shall have all of the following personal rights: (20) To be protected from involuntary transfers, discharges, and evictions..... This requirement was not met as evidenced by:
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Administrator agrees to review Title 22 Regulation sections 87468.2 and 87224 regarding Personal Rights and Eviction Procedures. Licensee to provide LPA Colvin with self-certification of review of those regulation sections and Statement of Understanding regarding what R1's rights
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Based on interviews conducted, the Licensee did not comply with the above regulation with at least one resident. LPA Colvin confirmed that R1 was not permitted to re-enter the facility upon discharge from the hospital. This was an immedaite personal rights violation of R1.
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were to return to the facility. Self-cetification and Statement of Understanding due by Plan of Correction date of 7/20/22.
Type B
07/29/2022
Section Cited
CCR
87506(e)
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Resident Records: (e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This requirement was not met as evidenced by:
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Administrator to provide LPA Colvin with Statement of Understanding regarding retention of resident records. Administrator to additionally provide LPA Colvin with plan to ensure that important resident documents are not lost when given to emergency personnel in the future. Statement of Understanding and plan
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Based on record review and interview, the Licensee did not comply with the above requirement with at least one resident. LPA Colvin observed that R1's file did not contain a LIC602 Physician's Report. Administrator admits to no longer possessing the document. This is a potential health risk to R1.
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for future resident records to be submitted to LPA Colvin by Plan of Correction date of 7/29/22.
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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3