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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604688
Report Date: 01/08/2025
Date Signed: 01/08/2025 02:01:42 PM

Substantiated


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
03/18/2024 and conducted by Evaluator Ramon Serrano
COMPLAINT CONTROL NUMBER: 08-AS-20240318151853
FACILITY NAME:VILLA KALI MAFACILITY NUMBER:
374604688
ADMINISTRATOR:AMUNDSON, ASHLEYFACILITY TYPE:
772
ADDRESS:17676 VISTA RANCHO COURTTELEPHONE:
(760) 683-5152
CITY:RANCHO SANTA FESTATE: CAZIP CODE:
92067
CAPACITY:6CENSUS: 3DATE:
01/08/2025
UNANNOUNCEDTIME BEGAN:
09:46 AM
MET WITH:Elizabeth PowellTIME COMPLETED:
02:24 PM
ALLEGATION(S):
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Staff did not distribute medication as prescribed
Licensee did not ensure that staff had a criminal record clearance
Staff did not treat clients with dignity
Staff did not conduct client safety checks
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ramon Serrano, conducted an unannounced Complaint Visit. LPA introduced himself and discussed the purpose of the visit with Operations Manager Elizabeth Powell.

Community Care Licensing (CCL) has investigated the above allegations. The investigation consisted of records review, staff and client interviews.

It was alleged that staff did not distribute medication as prescribed. It was reported that Staff 1 (S1) was overheard by a client, discussing out loud that Staff 2 (S2) made a mistake with a client's medication. LPA interviewed Staff 1 (S1) who stated that S1 was always correcting S2 due to S2 not being "on top of their stuff." S1 stated that S2 was "very sloppy with everything." S1 stated that S2 had a client that was given a GERD medication once every day. S1 stated that one day S2 gave the client the GERD medication twice on the same day. S1 could not recall the date that the medication error occurred.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025
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 5
Control Number 08-AS-20240318151853
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: VILLA KALI MA
FACILITY NUMBER: 374604688
VISIT DATE: 01/08/2025
NARRATIVE
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LPA reviewed internal facility medication reports dated December 2023 through March 2024. LPA discovered medication errors involving GERD medication on the following dates 12/21/23 and 12/22/23. It should be noted that these medication errors were not reported to CCL.

LPA interviewed Operations Manager (OM) who stated that she recently "took over" for the previous OM. OM stated that she has discovered that the facility was not submitting incident reports to CCL as required. OM stated that as of now when a medication error occurs the staff are to inform "quality control" staff member of the error and also fill out an incident report which is then submitted to CCL. OM stated that she implemented a new "health and safety" binder which contains all of the medications errors by date. OM stated that all of the medication errors are also uploaded to the clients chart.

It was alleged that Licensee did not ensure that staff had a criminal record clearance. It was reported that a staff member was working at the facility without a finger print clearance. LPA reviewed the background clearance status for all of the staff members employed at the facility. The records indicated that all staff members had undergone the necessary criminal background checks and fingerprint clearance as required by licensing regulations, with the exception of two employees. The “start dates” of two employees were determined to be prior to their criminal record clearance. The Licensee could not provide documentation indicating that the staff members started after they received their criminal record clearance

It was alleged that staff did not treat clients with dignity. It was reported that the Operations Manager (OM) was rude and a bully towards clients in care. LPA interviewed Client 1 (C1) (an LIC 811 Confidential Names List was provided to the facility representative to identify the client) who stated that they lived at the facility January 2024 through February 2024. C1 stated that OM was a difficult personality and OM would come off as very abrasive and condescending. OM was often rude and rejected all C1 requests for things that would have improved C1’s experience at the facility.

The current Operations Manager stated that she was asked to move over to the Rancho Santa Fe facility and although she did not have details as to what happened she was informed that their were some complaints regarding the previous Operations Manager specifically about her attitude towards other people.
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 08-AS-20240318151853
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: VILLA KALI MA
FACILITY NUMBER: 374604688
VISIT DATE: 01/08/2025
NARRATIVE
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It was alleged that staff did not conduct client safety checks. It was reported that C1 and other clients were on suicide watch however, staff did not conduct fifteen minute checks on the clients. LPA interviewed C1 who stated that there were several occasions when C1 was on “suicide watch” and was often sleeping during the safety checks. C1 further stated that on nights when C1 was not asleep and knew safety checks were required every X amount of time, that timing was not followed closely.

LPA reviewed several client “safety check” records dated January 19, 2024, March 5 2024 and March 9, 2024. The safety check records did not indicate a start or end time. The records were always missing staff initials on several of the required safety checks.

Based upon the foregoing, the above listed allegations are substantiated. This finding means that the preponderance of the evidence standard has been met and the allegations are valid. Deficiencies are cited in accordance with California Code of Regulations, Title 22 and are noted on the attached LIC 9099-D.

An exit interview was conducted with Elizabeth Powell and a copy of this report and Licensee/Appeal Rights (LIC9058, 3/22) were provided to Elizabeth Powell whose signature below confirms receipt of documents.
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 08-AS-20240318151853
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: VILLA KALI MA
FACILITY NUMBER: 374604688
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/06/2024
Section Cited
CCR
81075(b)(5)(B)
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...Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met, as evidenced by:
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Operations Manager offered to ensure that all staff receive medication administration training. Proof of traning will be provided to Community Care Licensing by the POC due date 12/6/24. This deficiency was cleared on 12/6/24.
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Based upon staff interview and records review client was administered two doses of medication, that was only suppose to be given once a day. This posed a potential health risk to 1 of 4 clients in care.
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Type B
01/29/2025
Section Cited
CCR
80019(c)
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Prior to the Department issuing a licensee, the applicant, administrator and any adult other than a client, residing in the facility shall obtain a California criminal record clearance or exemption as specified in Health and Safety Code section 1522(a)(4).
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Operations Manager stated she will create a new policy for documenting new staff members. that will prevent any staff from starting prior to criminal record clearance. Will send LPA new policy by 1/29/25.
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Based upon records review two staff members began working prior to receiving their criminial record clearance. This posed a potential safety risk to 4 of 4 clients 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.
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 08-AS-20240318151853
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: VILLA KALI MA
FACILITY NUMBER: 374604688
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/29/2025
Section Cited
CCR
76525(a)(14)
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Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section...To dignity, privacy, respect and humane care,
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Operations manager stated she will conduct a staff training focusing on clients personal rights and treating clients with dignity and respect. LPA will receive this signed training by 1/29/25
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Based upon staff and client interviews the operations manager did not treat the clients with dignity. This posed a potential personal rights risk to 4 of 4 clients in care.
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Type B
01/29/2025
Section Cited
CCR
77103(g)
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A client placed in behavioral restraint or seclusion shall be checked at least every 15 minutes...A written record shall be kept of these checks and maintained in the individual patient's health record.
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Operations manager stated she willl conduct a safety checks training focusing on documenting accurately and including more detailed information on the safety check log. LPA will receive this signed training and new safety log by 1/29/25
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Based upon records review and client interview the clients on "suicide watch" were not checked every 15 minutes and an accurate written record was not maintained for the clients. This posed a potential health and safety risk to 4 of 4 clients 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.
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5