374604525-1-16-2024-08-AS-DPOL-CZXTQ8-20240129135531

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604525
Report Date: 01/16/2024
Date Signed: 01/16/2024 11:17:37 AM

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
01/10/2024 and conducted by Evaluator Renita Hall

COMPLAINT CONTROL NUMBER: 08-AS-20240110153616

FACILITY NAME:	CANYON GUEST HOME		FACILITY NUMBER:	374604525
ADMINISTRATOR:	RAPHAEL, DANIEL		FACILITY TYPE:	740
ADDRESS:	4224 EMET COURT		TELEPHONE:	(858) 285-0811
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92117
CAPACITY:	6	CENSUS: 6	DATE:	01/16/2024
		UNANNOUNCED	TIME BEGAN:	09:13 AM
MET WITH:	Marilou De Le Pena, House Manager		TIME COMPLETED:	11:20 AM

ALLEGATION(S):

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Staff does not ensure toileting assistance is provided to resident in care
Staff allow resident to stay in soiled clothing for an extended period of time.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Renita Hall conducted an unannounced complaint visit opened complaint, and delivered findings regarding the above-mentioned allegations. LPA gained access to the facility, identified herself, and met with Marilou De Le Pena, House Manager to discuss the purpose of the visit.

On January 10, 2024, the department received a complaint that: the staff does not ensure toileting assistance is provided to the resident in care and staff allow the resident to stay in soiled clothing for an extended period.

The Reporting Party: RP was interviewed to obtain their account of the events and stated that the resident was on Hospice and could stand to use the toilet but with assistance and admitted that Resident 1 (R1) legs are contracted and one leg is weaker than the other. A review of records indicated that R1 is non-ambulatory with incontinence impairment with a secondary diagnosis of Parkinson's disease and Dementia.

Continued on 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Renita Hall	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20240110153616

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: CANYON GUEST HOME	FACILITY NUMBER: 374604525
	VISIT DATE: 01/16/2024

NARRATIVE

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The staff interviewed stated that R1 needed a two-person assist due to the non-ambulatory status of the resident. Staff used the Hoyer lift to properly change and clean R1 in the bed to reduce the number of injuries to staff and fall risks to R1. Staff followed incontinence changing schedule for R1.

The Department’s investigation consisted of interviews with staff, outside sources, and a review of records. The allegations that staff does not ensure toileting assistance is provided to the resident in care and that staff allows the resident to stay in soiled clothing for an extended period have not been corroborated with interviewees. Based on interviews, and records review, a preponderance of evidence does not exist to prove that the alleged violation(s) occurred, therefore the allegations are UNSUBSTANTIATED.

An exit interview was conducted with Marilou De Le Pena, House Manager. A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided to the House Manager and her signature on this report confirms receipt of the Licensee Rights.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Renita Hall	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024

LIC9099 (FAS) - (06/04)

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