374604667-5-12-2024-08-AS-JLOT-D7Q47Z-20240731185158

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604667
Report Date: 05/10/2024
Date Signed: 05/12/2024 09:27:09 AM

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
05/03/2024 and conducted by Evaluator Daniel Pena

COMPLAINT CONTROL NUMBER: 08-AS-20240503163357

FACILITY NAME:	MISSION VILLA WEST		FACILITY NUMBER:	374604667
ADMINISTRATOR:	ENGDAW, AMSAL D.		FACILITY TYPE:	740
ADDRESS:	2335 CAMINO DEL RIO SOUTH		TELEPHONE:	(619) 501-1244
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92108
CAPACITY:	6	CENSUS: 5	DATE:	05/10/2024
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Amsal Engdaw, Administration and Teresita Yap, Caregiver		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Licensee did not administer medication as prescribed
Staff did not treat resident with dignity
Staff handled resident roughly, resulting in bruising
Licensee did not assist resident(s) with incontinence care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Daniel Pena conducted an unannounced visit to the facility. LPA was met at the entrance by Administrator, Amsal Engdaw and Caregiver, Teresita Yap. After introducing and identifying himself, LPA was allowed in the facility. LPA discussed with Ms. Engdaw, the purpose of the visit which was to initiate a complaint investigation. Upon conclusion of the visit, LPA delivered findings to Ms. Yap.

There were two (2) staff, and five (5) residents present on the day of LPA’s visit. During the visit, LPA conducted a health and safety check and did not observe any health and safety concerns.

On May 3, 2024, Community Care Licensing Division (CCLD) received this complaint. The allegations reported include; licensee did not administer medication as prescribed, did not assist residents with incontinence care, did not treat residents with dignity and handled residents roughly, resulting in bruising.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024

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-20240503163357

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: MISSION VILLA WEST	FACILITY NUMBER: 374604667
	VISIT DATE: 05/10/2024

NARRATIVE

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The Department’s investigation consisted of facility inspection, review of facility and resident records and interviews with pertinent residents, staff, and outside sources.

The facility is licensed to serve six elderly non-ambulatory residents, one of whom may be bedridden, and three residents receiving hospice care. LPA reviewed resident, facility, and hospice care records. The records were complete. LPA observed resident medications were packaged, organized and revealed no indication staff does not administer medications as prescribed.

Interviews with residents and record reviews produced no evidence that staff do not provide incontinent assistance. Per interviews with staff, staff rotates residents every two hours and changes undergarments as needed. Residents said they were regularly rotated and changed.

None of the residents expressed concerns with any of their care. None of the residents stated that staff does not afford them dignity and respect. Residents also provided no information to support the allegation that staff handles them roughly. Staff denied handling residents roughly or treating them without dignity.
Staff interviews did not give LPA any indication that they do not regularly provide resident’s assistance with Activities of Daily Living (ADL). During the inspection, LPA observed the facility to be neat, organized and clean. Residents were wearing clean clothing and bedding appeared clean without offensive odors.

Outside source interviews offered no information to substantiate the allegations.

The Department has investigated the aforementioned allegations. Based on interviews, LPA observation and review of facility and hospice records, LPA found insufficient evidence to prove the allegations occurred as reported. The preponderance of evidence standard was not met; therefore, the allegations are Unsubstantiated.

An exit interview was conducted with Ms. Yap, to whom a copy of this report and Licensee/Appeals Rights (LIC 9058 01/16) were provided.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024

LIC9099 (FAS) - (06/04)

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