374604717-11-25-2024-08-AS-JLOT-DBDSZA-20241126131850

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604717
Report Date: 11/25/2024
Date Signed: 11/25/2024 11:57:23 AM

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
09/06/2024 and conducted by Evaluator Rebecca A Ruiz

COMPLAINT CONTROL NUMBER: 08-AS-20240906142829

FACILITY NAME:	HACIENDA MISSION SAN LUIS REY, THE		FACILITY NUMBER:	374604717
ADMINISTRATOR:	BUHLE, DIANE		FACILITY TYPE:	740
ADDRESS:	4000 MISSION AVE		TELEPHONE:	(520) 797-4000
CITY:	OCEANSIDE	STATE: CA	ZIP CODE:	92057
CAPACITY:	294	CENSUS: 167	DATE:	11/25/2024
		UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Memory Care Director Bianca Tapia		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff did not ensure that resident received phone calls

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced complaint visit to conduct follow up and deliver findings regarding the above-mentioned allegation. LPA identified herself to, was greeted by, and explained the purpose of the visit to Memory Care Director Bianca Tapia.

During today’s visit, LPA observed residents in care, obtained copies of facility records, and interviewed staff.

The Department’s investigation consisted of interviews with residents, staff, and outside sources, records review, and a tour of the facility. It was alleged that staff did not ensure that resident received phone calls, specifically Resident 1 (R1). Review of R1’s physician report dated October 2023 revealed that R1 had a diagnosis of major cognitive impairment and was confused and disoriented, but was able to follow directions and communicate needs.

Continued on LIC9099-C page...

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE:	DATE: 11/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024

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-20240906142829

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: HACIENDA MISSION SAN LUIS REY, THE	FACILITY NUMBER: 374604717
	VISIT DATE: 11/25/2024

NARRATIVE

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Review of R1’s assessment records dated November 2024 revealed that R1 was able to answer phone calls independently but was unable to make calls or remember phone numbers and required staff assistance to make phone calls.

Interviews with staff revealed that some residents would ask to make a phone call or would request staff assistance to make phone calls. If residents were unable to make phone calls independently, did not have a personal cell phone or land line, or did not recall the number of the person the resident wanted to speak with, staff would assist residents to make phone calls using the telephone located in the medication room. Interviews with staff also revealed that the phone in the medication room was available for residents to use without staff assistance. Interviews with staff and outside sources revealed that outside individuals would call the medication room and would request to speak with residents. If the resident was unavailable due to participating in activities and meals, asleep, or out in the community, staff informed the individual that the resident was unavailable and would pass along the message that the individual had called to speak with the resident. Interviews revealed that staff would give the resident a note stating that the individual called and asked the resident to call the individual. Interviews with staff revealed that R1 had a personal telephone that was set up by R1’s responsible person and R1 used it to make telephone calls independently. Additionally, interviews with staff revealed that R1 would occasionally ask to make phone calls using the phone in the medication room and staff would assist R1 with dialing the number. However, R1 would occasionally not know the number to the individual R1 was trying to reach and R1 was unable to complete the phone call. Interviews with staff revealed that on at least one occasion, R1 became agitated following a phone call with outside individuals. Interviews with residents, including R1, did not reveal any concerns regarding residents’ ability to maintain contact with outside individuals via telephone or during in-person visitation. Interviews with staff revealed that staff were aware of residents’ personal rights to visitation, making phone calls, and keeping in communication with family, friends, and outside individuals.

The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of the evidence has not been met, therefore, this allegation is deemed unsubstantiated.

An exit interview was conducted with Resident Care Director Carri Collins, Memory Care Director Bianca Tapia, and Business Office Manager Kristine Gutierrez, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).

SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE:	DATE: 11/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024

LIC9099 (FAS) - (06/04)

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