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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604732
Report Date: 07/26/2024
Date Signed: 07/26/2024 04:54:58 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
02/13/2024 and conducted by Evaluator Sabel Martinez
COMPLAINT CONTROL NUMBER: 08-AS-20240213114707
FACILITY NAME:MENTAL HEALTH CENTER OF SAN DIEGO LLCFACILITY NUMBER:
374604732
ADMINISTRATOR:POTLA, PRAVESHFACILITY TYPE:
772
ADDRESS:2075 TORREY PINES ROADTELEPHONE:
(858) 285-9883
CITY:LA JOLLASTATE: CAZIP CODE:
92037
CAPACITY:6CENSUS: 4DATE:
07/26/2024
UNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Program Administrator Pravesh PotlaTIME COMPLETED:
03:35 PM
ALLEGATION(S):
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Treatment plan was not prepared with client
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced complaint investigation visit to deliver findings. The LPA introduced himself and disclosed the purpose of the visit to Residential Operations Manager Alexa Pina. Program Administrator Pravesh Potla arrived during the visit and assisted the LPA.

Throughout the investigation, the Department secured pertinent records and conducted interviews with external and internal sources.

It was alleged a treatment plan was not prepared with a client. On 2/13/24, it was reported to the Department Client # 1’s (C1) treatment plan was no completed with C1. Review of records revealed C1 was admitted to the facility on 1/24/24. A review of C1’s treatment plan confirmed the plan was not completed, signed, and dated until 2/7/24. An interview with the program administrator confirmed this information to be true.
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024
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 5
Control Number 08-AS-20240213114707
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: MENTAL HEALTH CENTER OF SAN DIEGO LLC
FACILITY NUMBER: 374604732
VISIT DATE: 07/26/2024
NARRATIVE
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Additionally, a plan of correction had been formulated where training was implemented to address this deficiency.

Based on evidence obtained, the deficiency was cited in an LIC 9099D, and the plan of correction cleared on today’s date.

An exit interview was conducted with Administrator Pravesh Potla, to whom a copy of this report, LIC 9099D, LIC 811 Confidential names list, and Licensee/Appeals Rights (LIC 9058), were provided via email. An email read receipt confirms the documents were received by the administrator.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 08-AS-20240213114707
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: MENTAL HEALTH CENTER OF SAN DIEGO LLC
FACILITY NUMBER: 374604732
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/26/2024
Section Cited
CCR
81068.2(b)(3)
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81068.2 Needs and Services Plan (b) For each client admitted, the licensee shall ensure that a written Needs and Services Plan is started prior to admission, and completed prior to or within 72 hours of admission, that must include: (3) A written treatment/rehabilitation plan as required by California Code of Regulations, title 9, subchapter 3, article 3.5, section 532.2(c). This requirement was not met as evidenced by:
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Plan of Correction was cleared on today's date. The facility has implemented training to address the deficiency and has provided the LPA with documentation.
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Based on review of records and an interview, the licensee did not ensure a written treatment/ rehabilitation plan was maintain according to California code of regulations, title 9, which posed a health, safety, and personal rights risk to 1 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: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
02/13/2024 and conducted by Evaluator Sabel Martinez
COMPLAINT CONTROL NUMBER: 08-AS-20240213114707

FACILITY NAME:MENTAL HEALTH CENTER OF SAN DIEGO LLCFACILITY NUMBER:
374604732
ADMINISTRATOR:POTLA, PRAVESHFACILITY TYPE:
772
ADDRESS:2075 TORREY PINES ROADTELEPHONE:
(858) 285-9883
CITY:LA JOLLASTATE: CAZIP CODE:
92037
CAPACITY:6CENSUS: 4DATE:
07/26/2024
UNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Program Administrator Pravesh PotlaTIME COMPLETED:
03:35 PM
ALLEGATION(S):
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Facility did not have a client's signed admission agreement
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced a follow up complaint investigation visit, and delivered complaint findings. The LPA introduced himself and disclosed the purpose of the visit to Residential Operations Manager Alexa Pina. Program Administrator Pravesh Potla arrived during the visit and assisted the LPA.

Throughout the investigation, the Department secured records and conducted interviews with external and internal sources.

It was alleged the facility did not have a client's signed admission agreement. On 2/13/24, it was reported to the Department facility staff did not sign Client # 1’s (C1) admission agreement on the day of admission. Review of records revealed the C1 was admitted and signed the admission agreement on 1/24/24. Facility staff signed the admission agreement on 1/25/24. Per California Code of Regulation, Title 22, the admission agreement must be signed no later than seven (7) days after admission.
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 08-AS-20240213114707
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: MENTAL HEALTH CENTER OF SAN DIEGO LLC
FACILITY NUMBER: 374604732
VISIT DATE: 07/26/2024
NARRATIVE
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Based on the evidence obtained, the allegation was Unsubstantiated.

An exit interview was conducted with Pravesh Potla, to whom a copy of this report, and Licensee/Appeals Rights (LIC 9058), were provided via email. An email read receipt confirms the documents were received by Pravesh Potla.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5