374604614-11-3-2023-08-AS-DPOL-CY323S-20231129160248

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604614
Report Date: 11/03/2023
Date Signed: 11/03/2023 12:00:23 PM

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
10/31/2023 and conducted by Evaluator Renita Hall

COMPLAINT CONTROL NUMBER: 08-AS-20231031142419

FACILITY NAME:	ANABELLA HOMECARE		FACILITY NUMBER:	374604614
ADMINISTRATOR:	VON RIVERA ALLANE		FACILITY TYPE:	740
ADDRESS:	14249 HIGH VALLEY		TELEPHONE:	(406) 998-8022
CITY:	POWAY	STATE: CA	ZIP CODE:	92064
CAPACITY:	6	CENSUS: 4	DATE:	11/03/2023
		UNANNOUNCED	TIME BEGAN:	09:41 AM
MET WITH:	Lawrence Vergara, Caregiver Anafe Rivera Site Manager Von Rivera, Administrator		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff did not feed resident in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Renita Hall, conducted an unannounced visit to initiate a complaint investigation regarding the above-mentioned allegation and deliver findings. LPA were allowed entry by Lawrence Vergara, Caregiver. LPA identified herself and disclosed the purpose of the visit and elements of the complaint with the Caregiver. The site Manager, Anafe Rivera and Administrator, Von Rivera joined the interview a few minutes later.

On October 31, 2023 an allegation was made that staff members at Anabella Home did not feed a resident in care, which raised concerns about potential neglect.

The resident in question was no longer living at the facility as family came to pick up their belongings and decided to care for resident themselves.

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: 11/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023

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-20231031142419

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: ANABELLA HOMECARE	FACILITY NUMBER: 374604614
	VISIT DATE: 11/03/2023

NARRATIVE

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The Reporting Party: RP was interviewed to obtain their account of the events and stated that resident was on Hospice and did not know what type of diet the resident was on at the time of reporting the complaint.

Residents Interviewed: During the interview with the resident, they confirmed that they had received their meals regularly and did not experience any instances of not being fed by the staff. Staff Interviewed: All staff members denied the alleged allegation and provided consistent statements that the residents were served meals as per their dietary requirements.

Other outside sources stated that they witnessed staff feeding the resident and the resident was only in care for a few days before they "medical out."

Documentation Review: Relevant documentation, including resident care records, meal schedules, and any incident reports, were reviewed to identify any discrepancies or patterns. No discrepancies were found

Based on the review of records, and statements the allegation of: Staff did not feed resident in care is Unsubstantiated due to a lack of conclusive evidence. A finding that is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

An exit interview was conducted with Von Rivera, Administrator. A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided to the Caregiver and his 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: 11/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023

LIC9099 (FAS) - (06/04)

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