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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604508
Report Date: 06/21/2022
Date Signed: 06/21/2022 04:04:25 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
06/17/2022 and conducted by Evaluator Crystal Colvin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220617091012
FACILITY NAME:ESTANCIA SENIOR LIVINGFACILITY NUMBER:
374604508
ADMINISTRATOR:SMITH, LAWRENCEFACILITY TYPE:
740
ADDRESS:1735 SO MISSION ROADTELEPHONE:
(240) 595-6061
CITY:FALLBROOKSTATE: CAZIP CODE:
92028
CAPACITY:128CENSUS: 32DATE:
06/21/2022
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Beatrice Bracamonte - Memory Care DirectorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Resident had unwitnessed fall resulting in injury.

Facility staff are not assisting resident with hygiene needs.

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 Memory Care Director (MCD) Beatrice Bracamonte. Below is a summary of the complaint investigation findings:

Regarding allegation "Resident had unwitnessed fall resulting in injury.": LPA Colvin reviewed Resident's (R1) file including recent staff notes, doctor communications (faxes), and assessments. LPA Colvin observed that since admission to the facility in 2021, R1 has sustained multiple falls (10/11/21, 1/7/22, 5/12/22), one of which resulted in a head injury (10/11/21). The fall which resulted in injury was prior to the facility's current license, and therefore cannot be considered for this allegation. On 6/15/22, R1 was observed by staff to have a bruise and bump on their forehead. In interviews with staff members, they maintain that they cannot confirm the source of the bruise/bump, and that it could be from the resident hitting their head another way other than a fall. R1 was not sent out to the hospital or seen by a doctor, however, in review of R1's file LPA Colvin
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: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022
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 5
Control Number 18-AS-20220617091012
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: ESTANCIA SENIOR LIVING
FACILITY NUMBER: 374604508
VISIT DATE: 06/21/2022
NARRATIVE
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observed a written note (observational staff notes) from the staff member (S1) who first observed the injury. In this note, S1 states "This morning we found the resident with a bruise on his forehead, apparently from a fall in the night". Since facility staff have no evidence of the bruise and bump coming from anything other than a fall and the resident has numerous past documented falls, the most likely explanation is that R1 fell during the night, as noted in S1's staff note. Despite R1's documented history of multiple falls, R1 was not reassessed by the facility and no changes were made to R1's Service Plan to address R1's potential fall risk.
Therefore, due to record review and interviews, the allegation of "Resident had unwitnessed fall resulting in injury." is SUBSTANTIATED.

Regarding allegation "Facility staff are not assisting resident with hygiene needs.": LPA Colvin reviewed pertinent records for Resident (R1) and interviewed care staff and MCD Beatrice. LPA Colvin additionally met with R1 in their private room and observed R1's fingernails to be overgrown. Through interviews conducted, LPA Colvin learned that while the facility has services available for R1 to have their nails cleaned and filed (at an additional charge), facility staff did not notify R1's representative of the status of R1's nails, and their need for cleaning/filing. MCD Beatrice admitted to R1's nails needing attention at their current state, and that a conversation was had with R1's representative only after the representative brought up the concern to MCD Beatrice during a meeting at the facility.

Due to the facility failing to notify the representative of the need for R1's nails to be cleaned/filed, facility staff either failed to observe this unmet need or failed to ensure R1 received care for their nails. R1's file has numerous documents stating that R1 needs assistance with reminders for grooming. Therefore, based on observations and interviews, the allegation "Facility staff are not assisting resident with hygiene needs." 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 Memory Care Director Beatrice Bracamonte during the exit interview.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 18-AS-20220617091012
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: ESTANCIA SENIOR LIVING
FACILITY NUMBER: 374604508
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/24/2022
Section Cited
CCR
87466
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Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs... This requirement was not met as evidenced by:
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Licensee agrees to reassess R1 as well as confirm with R1's doctor regarding potential care plans for R1 to address fall risk. Licensee to provide LPA Colvin with results of reassessment and propsed new care plan by Plan of Correction date of 6/24/22.
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Based on record review and interview, the Licensee did not comply with the above regulation with one resident (R1). LPA Colvin observed that R1 has a documented history of falls since admission to the facility, but facility staff have not reassessed R1 to address this. This is an immediate safety concern for R1.
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Type B
07/01/2022
Section Cited
CCR
87465(a)(1)
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Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall...provide for assistance in obtaining such care,...(1) The licensee shall arrange, or assist in arranging, for medical and dental care...to the conditions and needs of residents.
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Licensee agrees to establish a procedure for care staff to check residents (such as during showers) for unmet physical needs, and alert Administrative staff, who shall then contact the resident's representatives and/or doctors in a timely manner to aide with arraingement of care. Plan to be submitted to LPA Colvin by
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This requirement was not met by: Based on observations and interviews, the Licensee did not comply with the above regulation with one resident (R1). LPA Colvin confirmed that R1's nails need to be cleaned/filed, and that R1's representative had to bring it up to staff. This is a potential health risk to R1.
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Plan of Correction date of 7/1/22.
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: 06/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
06/17/2022 and conducted by Evaluator Crystal Colvin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220617091012

FACILITY NAME:ESTANCIA SENIOR LIVINGFACILITY NUMBER:
374604508
ADMINISTRATOR:SMITH, LAWRENCEFACILITY TYPE:
740
ADDRESS:1735 SO MISSION ROADTELEPHONE:
(240) 595-6061
CITY:FALLBROOKSTATE: CAZIP CODE:
92028
CAPACITY:128CENSUS: DATE:
06/21/2022
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Beatrice Bracamonte - Memory Care DirectorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility staff refused to provide responsible party with a copy of SIRs.

Administrator is not present on the premises as required.
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 Memory Care Director (MCD) Beatrice Bracamonte. Below is a summary of the complaint investigation findings:

Regarding allegation "Facility staff refused to provide responsible party with a copy of SIRs.": LPA Colvin conducted interviews and confirmed that Resident's (R1) representative was not provided with a copy of a Special Incident Report (SIR) for an injury sustained by R1 on 6/15/22. LPA Colvin additionally learned that R1's representative was told that a cpoy would be available once the SIR is approved for submission to Community Care Licensing by the Licensee's Regional Manager. Therefore, since the SIR is not yet finalized, and facility staff will supply a copy of the finalized document to the requesting party, the allegation "Facility staff refused to provide responsible party with a copy of SIRs." is UNSUBSTANTIATED.


Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20220617091012
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: ESTANCIA SENIOR LIVING
FACILITY NUMBER: 374604508
VISIT DATE: 06/21/2022
NARRATIVE
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Regarding allegation "Administrator is not present on the premises as required.": LPA Colvin interviewed staff regarding the allegation and additionally attempted to obtain records for review. LPA Colvin was informed that the Administrator does not have a written schedule for LPA Colvin to view, but that they are present during business hours at the facility. LPA Colvin interviewed staff who confirmed that the Administrator is generally present at the facility, and LPA Colvin observed that while the Administrator had a meeting to attend and was unable to sign this report, the Administrator was present during part of LPA Colvin's inspection today.

LPA Colvin additionally inquired as to who is in charge when the Administrator happens to not be present, and LPA Colvin was informed that Memory Care Director (MCD) Beatrice Bracamonte is in charge in the Administrator's absence. MCD was present during all of LPA Colvin's inspection and is present for the review and signing of the report. LPA Colvin reviewed Title 22 Regulations, which do not state a specific number of hours an Administrator must be present at the facility, only that they need to be there frequently enough to oversee. Additionally, Title 22 Regulations require for there to be a designated staff member to be in charge during any absence of the Administrator from the facility. LPA Colvin identified that MCD is in charge when the Administrator is out, and MCD is qualified to oversee operations in brief absences of the Administrator, as MCD has previously been an Administrator and had an Administrator certificate, and therefore has the knowledge and training required to adequately oversee a facility. LPA Colvin was not provided with any further evidence that the facility is without an Administrator as required, or that the Administrator is not at the facility frequently enough to oversee operations. Therefore, due to interviews and lack of evidence, the allegation "Administrator is not present on the premises as required" is UNSUBSTANTIATED.

A finding of UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted with Memory Care Director (MCD) Beatrice Bracamonte and a copy of this report was provided.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5