405802287-9-2-2022-29-AS-KBUY-CHVRR5-20220902131433

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405802287
Report Date: 09/01/2022
Date Signed: 09/02/2022 01:08:27 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/14/2021 and conducted by Evaluator Mark Jeffries

COMPLAINT CONTROL NUMBER: 29-AS-20210614161831

FACILITY NAME:	GARDEN VIEW INN		FACILITY NUMBER:	405802287
ADMINISTRATOR:	KOC DE JONG, DIMFNA		FACILITY TYPE:	740
ADDRESS:	7105 SAN GABRIEL RD		TELEPHONE:	(805) 462-2273
CITY:	ATASCADERO	STATE: CA	ZIP CODE:	93422
CAPACITY:	15	CENSUS: 11	DATE:	09/01/2022
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Cristal Cole/Med Tech		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff caused injuries to resident.
Staff handled resident in a rough manner.

INVESTIGATION FINDINGS:

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At 12:30pm on 09/01/2022, Licensing Program Analyst (LPA) Jeffries arrived at the facility to deliver final findings to the allegations to this complaint. LPA met with Cristal Cole/Med Tech announced the reason for the visit.

As to the allegation of, “Staff caused injuries to resident” and , It was discovered through documentation, and interviews that on 06/09/2021 at approximately 10:00pm that R1 suffered a fall in their room, on the first floor of the facility, that resulted in injury. Interview of Administrator on 06/16/22 at 12:30pm, indicate that R1 was alone in their room on the first floor and the fall was unwitnessed. Additionally, S2 was interviewed on 06/16/21 at 11:25am, and stated they were working on the second floor and heard of the fall from S1 and did not witness the fall, as they were working on the second floor during the time of the fall according to documentation of incident reported dated 06/09/2021 and additional documented account in report form by S1 dated 06/09/2021. Documentation of a serious incident report (SIR) dated 06/12/2021 details S1 was working with another resident when they heard “a loud bang”,
CONTINUED on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark Jeffries	TELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022

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 29-AS-20210614161831

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GARDEN VIEW INN	FACILITY NUMBER: 405802287
	VISIT DATE: 09/01/2022

NARRATIVE

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it was reported that S1 then went into the room and discovered R1 on the floor. Interviews of S4 -6 did not have any knowledge of the fall. R1 later told staff that she did not fall but a male person had hit her. R1 has a diagnosis of dementia, and was unable to be interviewed for this investigation. 6 Residents who were interviewed were asked if they had been treated or moved roughly by staff at any time during their stay at the facility and no resident had any issues with being treated roughly. Staff were also interviewed and Staff 1 -6 stated that they have never been rough with residents, nor have they witnessed other staff being rough with residents in care at this facility. Due to documentation and interviews, at this time there is not enough evidence to support the allegation of, “Staff caused injuries to resident,” and is unsubstantiated at this time.

As to the allegation of, “Staff handled resident in a rough manner.” It was discovered through interviews and documentation that daily resident progress notes were taken of each resident. The progress notes during the time of the allegation to this complaint were reviewed, April 2021 through July 2021. Incident reports submitted by the facility were also reviewed during this period, April 2021 through July 2021. There was no evidence of residents injured by daily progress notes of staff or incident reports submitted by the facility during this time period. Additionally, 6 Residents who were interviewed were asked if they had been treated or moved roughly by staff at any time during their stay at the facility and no resident had any issues with being treated roughly. Staff were also interviewed and Staff 1 -6 stated that they have never been rough with residents, nor have they witnessed other staff being rough with residents in care at this facility. Based on documentation and interviews there is not enough evidence to support the allegation of, “Staff handled resident in a rough manner.” and is unsubstantiated at this time.

Exit interview, report singed, and report emailed.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark Jeffries	TELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022

LIC9099 (FAS) - (06/04)

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