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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604533
Report Date: 11/17/2023
Date Signed: 11/17/2023 03:54:51 PM

Document Has Been Signed on 11/17/2023 03:54 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:SANTIANNA OAKMONT SIGNATURE LIVINGFACILITY NUMBER:
374604533
ADMINISTRATOR:EL RABAA, SAMFACILITY TYPE:
740
ADDRESS:2560 FARADAY AVETELEPHONE:
(442) 325-8090
CITY:CARLSBADSTATE: CAZIP CODE:
92010
CAPACITY: 226CENSUS: 164DATE:
11/17/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Executive Director Sam El-RabaaTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Sam El-Rabaa.

Today's visit was in response to an SOC341 Report of Suspected Dependent Adult/Elder Abuse, which licensee self-submitted to the CCLD San Diego Regional Office (received on 09/07/2023), involving Resident #1 (R1) and Staff #1 (S1). [See LIC 811 Confidential Names List for a description of person identifiers used in this report].

During today’s visit, LPA performed a facility tour and welfare check on R1, verifying they were safe. LPA collected copies of pertinent care, medical, and personnel records. LPA reviewed handwritten witness statements and time-stamped documents from Licensee’s internal investigation. LPA also interviewed pertinent staff and outside sources.

According to R1’s latest LIC602 Physician’s Report (dated 01/09/2023), they were diagnosed with Alzheimer’s type Dementia, but their doctor determined that R1 was continent of bowel and bladder. Licensee’s own Service Plan and internal care assessment (both dated 08/08/2023) corroborated that R1 had dementia but was independent with toileting tasks.

Due to their baseline memory loss, R1 was unable to participate as a reliable historian/interviewee about the incident. However, records and staff interviews showed: During the morning of 09/06/2023, S1 sat beside R1 on a couch and used their hand to touch R1’s upper thigh in a sexualized manner. S1 also touched the side of R1’s breast on a separate occasion. R1 did not suffer physical injuries as a result.

[CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: SANTIANNA OAKMONT SIGNATURE LIVING
FACILITY NUMBER: 374604533
VISIT DATE: 11/17/2023
NARRATIVE
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[CONTINUED FROM LIC 809]

Personnel records and staff interviews further showed: Facility management first became aware of allegations on 09/06/2023, and suspended S1 pending further investigation. On 09/09/2023, Licensee terminated S1’s employment, after concluding that S1 had engaged in “inappropriate touching.” Although Licensee timely investigated the incident, Licensee’s staff did not report the incident to local law enforcement (which is required upon receipt of an allegation of physical abuse). [CCLD subsequently cross-reported the incident to local law enforcement.]

According to Resident #1’s (R1’s) Face Sheet: R1 had a responsible person (RP) other than themselves. Via phone call, Licensee timely notified the RP of the incident, then on 09/11/2023 sent CCLD a written LIC624 Incident Report. However, per manager and outside source interviews, Licensee did not send a copy of the written incident report to R1’s responsible person, as was required to be done within seven (7) days of incident occurrence.

A preponderance of evidence exists to show that during the incident in question, licensee’s staff (S1) did not ensure R1 was free from abuse. A preponderance of evidence also exists to show that Licensee did not fully meet reporting requirements. Three (3) deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). Plans of Correction was jointly developed with the licensee.

An exit interview was conducted with El-Rabaa, to whom a copy of this report, the LIC 809-D pages, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 11/17/2023 03:54 PM - It Cannot Be Edited


Created By: Dang Nguyen On 11/17/2023 at 02:34 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: SANTIANNA OAKMONT SIGNATURE LIVING
FACILITY NUMBER: 374604533

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
11/18/2023
Section Cited
CCR
87468.2(a)(8)

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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: “(a)…residents…shall have all of the following personal rights: “(8) To be free from…physical, or sexual abuse.” This requirement was not met, as evidenced by:
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Per manager interview and corroborated by personnel records: Licensee suspended R1’s employment at the facility on 09/06/2023, and then terminated it on 09/09/2023. This resolved the immediate “Type A” risk. Licensee agreed to retrain current staff on: a) Resident’s Personal Rights in Privately Operated RCFE (as articulated in form LIC613C-2) and, b: Abuse and Neglect Prevention. Licensee agreed to E-mail LPA a copy the training sign-in sheet by 12/17/2023.
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Based on records and interviews, licensee’s staff (S1) did not ensure that 1 of 164 residents (R1) was free from physical or sexual abuse, which posed an immediate safety and personal rights risk to persons in care.
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Request Denied
Type B
12/17/2023
Section Cited
CCR87211(c)

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87211 Reporting Requirements: “(c) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours as required by Welfare and Institutions Code Section 15630(b)(1).”
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CCLD subsequently cross-reported the incident to local law enforcement. Licensee agreed to utilize a third-party source to retrain its staff on Abuse definitions and How to Be a Mandated Reporter in California. The training participants will include current facility staff and corporate Staff #3 (S3) and Staff #4 (S4). Licensee agreed to E-mail LPA the training sign-in sheet by the POC due date.
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This requirement was not met, as evidenced by: Based on records and interviews, for 1 of 164 residents (R1), licensee had knowledge of suspected physical abuse against them which did not result in serious bodily injury, and did not report it to the local law enforcement agency within twenty-four (24) hours. This posed a potential safety and personal rights risk to persons in care.
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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:Lizzette Tellez
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/17/2023 03:54 PM - It Cannot Be Edited


Created By: Dang Nguyen On 11/17/2023 at 02:38 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: SANTIANNA OAKMONT SIGNATURE LIVING
FACILITY NUMBER: 374604533

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
12/17/2023
Section Cited
CCR
87211(a)(1)(D)

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87211 Reporting Requirements: "(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified...(D) Any incident which threatens the welfare, safety or health of any resident."
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During today’s visit, Licensee E-mailed a copy of the LIC624 Incident Report to R1’s responsible person. Licensee agreed to utilize a third-party source to retrain pertinent facility managers on Regulation 87211 Reporting Requirements. The training participants will also include corporate Staff #3 (S3) and Staff #4 (S4). Licensee agreed to E-mail LPA the training sign-in sheet by the POC due date.
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This requirement was not met, as evidenced by: Based on records and interviews, 1 of 164 residents (R1) had an incident which threatened their welfare, safety, or health, and Licensee did not submit a written report of the incident to the person responsible for the resident within seven days of incident occurrence. This posed a potential personal rights risk to persons in care.
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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:Lizzette Tellez
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2023


LIC809 (FAS) - (06/04)
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