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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604722
Report Date: 11/19/2024
Date Signed: 11/19/2024 03:43:09 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
10/07/2024 and conducted by Evaluator Sabel Martinez
COMPLAINT CONTROL NUMBER: 08-AS-20241007090449
FACILITY NAME:NOVELLUS CLAIREMONT LLCFACILITY NUMBER:
374604722
ADMINISTRATOR:LAIRD, CANDIFACILITY TYPE:
740
ADDRESS:5219 CLAIREMONT MESA BLVD.TELEPHONE:
(858) 292-8044
CITY:SAN DIEGOSTATE: CAZIP CODE:
92117
CAPACITY:214CENSUS: 85DATE:
11/19/2024
UNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Executive Director Emily De La BarreTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff did not provide resident medication as prescribed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced follow up complaint investigation visit, and delivered complaint findings. The LPA introduced himself and disclosed the purpose of the visit to Executive Director Emily De La Barre.

It was alleged staff did not provide resident medication as prescribed. On 10/07/2024, it was reported to the Department staff did not provide Resident # 1 (R1) prescribed medication.

Although R1’s Physician’s Report noted that R1 did, and also noted R1 did not require assistance with medication management, review of R1’s care plan revealed R1’s did not require medication management, nor a service for medication assistance. Interviews with R1 and the facility administrator corroborated R1 managed R1’s medication and did not require assistance with medication management. Based on the evidence obtained, the allegation was Unsubstantiated.
(See LIC 9099C for continuation of report.)
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) -76-2351
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
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 2
Control Number 08-AS-20241007090449
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: NOVELLUS CLAIREMONT LLC
FACILITY NUMBER: 374604722
VISIT DATE: 11/19/2024
NARRATIVE
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An exit interview was conducted with De La Barre, to whom a copy of this report, LIC 811 Confidential names list, and Licensee/Appeals Rights (LIC 9058), were provided.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) -76-2351
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2