374604533-3-18-2024-08-AS-JLOT-D5STMG-20240531145106

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604533
Report Date: 03/18/2024
Date Signed: 03/18/2024 05:27:31 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 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
03/13/2024 and conducted by Evaluator Nacole Patterson

PUBLIC

COMPLAINT CONTROL NUMBER: 08-AS-20240313163516

FACILITY NAME:	SANTIANNA OAKMONT SIGNATURE LIVING		FACILITY NUMBER:	374604533
ADMINISTRATOR:	EL RABAA, SAM		FACILITY TYPE:	740
ADDRESS:	2560 FARADAY AVE		TELEPHONE:	(442) 325-8090
CITY:	CARLSBAD	STATE: CA	ZIP CODE:	92010
CAPACITY:	226	CENSUS: 162	DATE:	03/18/2024
		UNANNOUNCED	TIME BEGAN:	12:50 PM
MET WITH:	Executive Director Sam El Rabaa		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Licensee did not address concerns regarding door egress, resulting in injury.

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to initiate a complaint allegation and deliver findings regarding the above complaint allegation. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Sam El Rabaa.

On 3/13/24 it was alleged that the Licensee did not address concerns regarding door egress, resulting in injury. The Department’s investigation consisted of unannounced facility visit, interviews with facility staff, residents, outside sources, records review, and LPA observations. Staff interview revealed that the Executive Director (ED) and Maintenance Director (MD) had been in ongoing contact with residents and contractors regarding the adjustment of the doors. Staff interviews revealed that the doors were considered "fire rated" and weighted, which resulted in them closing quickly after opening. Staff interviews further revealed that outside contractors came to the facility to adjust the pounds per square inch (PSI) pressure on the hinges to slow down the door closure, and also for 6-month preventive maintenance.

(Continued on LIC9099-C p.2)

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Nacole Patterson	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024

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-20240313163516

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: SANTIANNA OAKMONT SIGNATURE LIVING	FACILITY NUMBER: 374604533
	VISIT DATE: 03/18/2024

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

(Continued from LIC9099 p.1)

Staff informed that proposals had been made to further correct the doors, and the information was communicated to residents during the monthly Town Hall meeting with the Executive Director. These statements by staff were corroborated by records from 2 (two) independent contractors, and the resident Town Hall meeting notes.

Residents interviewed confirmed that the doors were heavy and closed too quickly, resulting in a prior fall with minor injury. While residents expressed concern with possible future injuries regarding the doors, they also acknowledged that the Licensee had been working on the issue, but were dissatisfied with how long it has taken.

Outside source interview revealed knowledge of the residents' concerns about the doors, with no knowledge of what the Licensee had done to address the issue.

Records review revealed email communication, outside contractor proposals, invoices from work completed, and Town Hall meeting notes. These records gave evidence to the fact that the Licensee had been addressing the issue of the doors since November 2023 and communicating the progress to residents.

During an unannounced facility visit, LPA directly observed the doors in question, as well as their operation. LPA observed that the doors were slightly heavier than a regular door, and the bathroom doors closed quickly after being opened, with little resistance or delay. The doors and door frames contained permanent metal tags with serial numbers on them. The tags contained the following statements: "Meets UL 10C/NFPA 252 requirements positive pressure. Do not remove or cover this label". This gave evidence to the doors meeting code regulations.

Although the issue of the doors was proven to exist, evidence was not found to prove that the Licensee did not make efforts to correct it.

Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Executive Director Sam El Rabaa, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Nacole Patterson	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2