374604668-5-12-2024-08-AS-SJAB-D7PPBL-20240731111032

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604668
Report Date: 05/10/2024
Date Signed: 05/12/2024 09:25:51 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-20240503160031

FACILITY NAME:	MISSION VILLA EAST		FACILITY NUMBER:	374604668
ADMINISTRATOR:	ENGDAW, AMSAL		FACILITY TYPE:	740
ADDRESS:	2337 CAMINO DEL RIO SOUTH		TELEPHONE:	(619) 501-1788
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92108
CAPACITY:	6	CENSUS: 6	DATE:	05/10/2024
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Amsal Engdaw, Administrator/Maria Pacleb, Caregiver		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Licensee did not administer medication as prescribed
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 Caregiver, Maria Pacleb and Administrator, Amsal Engdaw. 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 Caregiver, Maria Pacleb.

There were two (2) staff, and six (6) 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 nature of the allegations is the Licensee did not administer medication as prescribed and did not ensure staff assists residents with incontinence care.

The Department’s investigation consisted of facility inspection, review of facility and resident records and

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-20240503160031

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 EAST	FACILITY NUMBER: 374604668
	VISIT DATE: 05/10/2024

NARRATIVE

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interviews with pertinent residents, staff, and outside sources.

The facility serves elderly residents, most of whom, are non-ambulatory and receiving hospice care. LPA reviewed the resident facility and hospice care documents and found no evidence to support facility staff do not provide medications as prescribed or assist residents with incontinence care. Per interviews with staff and residents, staff rotates residents twice an hour and changes undergarments as needed. Two residents were being treated for Stage 2 pressure injuries. Interviews and records indicate the injuries are healing and residents are receiving wound care.

None of the residents expressed concerns with any of their care. Staff interviews did not give LPA any indication that they were not carrying out care and supervision. LPA observed the facility to be neat, organized and clean. Residents were wearing clean clothing and bedding appeared clean without offensive odors. LPA observed resident medications and records. Medications were packaged and organized by resident and revealed no indication that they had not been administered as prescribed. Outside source interviews were complimentary of the facility and care being provided and 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. Pacleb, 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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