370804823-3-9-2022-08-AS-LTEZ-CD24QW-20220330191902

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 370804823
Report Date: 03/09/2022
Date Signed: 03/09/2022 04:55:04 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
07/01/2021 and conducted by Evaluator Rebecca A Ruiz

COMPLAINT CONTROL NUMBER: 08-AS-20210701162828

FACILITY NAME:	ST. PAUL'S VILLA		FACILITY NUMBER:	370804823
ADMINISTRATOR:	ELEANOR DOWNING		FACILITY TYPE:	740
ADDRESS:	2340 FOURTH AVENUE		TELEPHONE:	(619) 232-2996
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92101
CAPACITY:	200	CENSUS: 92	DATE:	03/09/2022
		UNANNOUNCED	TIME BEGAN:	03:20 PM
MET WITH:	LaTressa Downing		TIME COMPLETED:	04:10 PM

ALLEGATION(S):

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Licensee did not meet resident(s) incontinence needs
Licensee is not meeting resident(s) needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rebecca Ruiz and Licensing Program Manager (LPM) Lizzette Tellez conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegations. LPA and LPM were greeted by, identified themselves to, and explained the purpose of the visit with Executive Director Eleanor "LaTressa" Downing.

The Department’s investigation consisted of interviews with staff, residents, and outside sources, review of records, and a tour of the facility. It was alleged that the Licensee did not meet the incontinence needs of Resident #1 (R1). Executive Director was provided with LIC811 Confidential Names to identify R1. Review of R1’s medical assessment dated 10/8/2020 revealed that R1 did not have any cognitive or memory impairments and was able to communicate any needs or concerns. The medical assessment also stated that R1 was non-ambulatory, was unable to independently transfer to or from a bed, and was unable to care for own toileting needs.
Continued on LIC9099-C page.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Alexandre Vo	TELEPHONE: (619) 385-7506
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022

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 4

Control Number 08-AS-20210701162828

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ST. PAUL'S VILLA	FACILITY NUMBER: 370804823
	VISIT DATE: 03/09/2022

NARRATIVE

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Investigative interviews, including outside individuals who visited R1 daily and outside health agencies, revealed that R1 wore incontinence briefs, used a wheelchair, required someone to wheel R1 to the bathroom, and assist R1 to transfer from the wheelchair to the toilet. On or about 6/23/2021, R1 pulled the call light in R1’s room to alert staff that R1’s incontinence brief was soiled. R1 was told by an unidentified staff that R1 would have to wait until the next staff came in for their shift and R1 was left in the soiled brief for hours. Sometime in August 2021, R1’s incontinence brief was wet and R1 was told by an unidentified staff that R1 would have to wait four (4) hours before being changed. Interviews with residents and outside sources indicated that residents waited an average more than 30 minutes for staff to respond to the call light for assistance and had to wait to have incontinence briefs changed or receive assistance to the restroom. Review of the facility’s assisted living floor call light log for a period of 30 days revealed roughly 7% or approximately 152 instances where residents’ call lights were not responded to by staff for 20 minutes or more, including 20 times where the call light was not responded to. The facility’s call light system determined a call light was not responded to after 84 minutes had passed from the initial call. The call light log for R1 revealed seven (7) instances where R1’s call light was not responded to for 20 minutes or more and five (5) instances where R1’s call light was not responded to as determined by the call light system. The Department was unable to interview R1.

It was alleged that the Licensee did not meet the needs of residents. Investigative interviews and record review revealed that R1 required assistance and would utilize the call light in R1’s bedroom to request assistance from facility staff. Review of the facility’s assisted living floor call light log for a period of 30 days revealed roughly 7% or approximately 152 instances where residents’ call lights were not responded to by staff for 20 minutes or more, including 20 times where the call light was not responded to. The facility’s call light system determined a call light was not responded to after 84 minutes had passed from the initial call. Interviews with residents and outside sources indicated that residents waited an average more than 30 minutes for staff to respond to the call light for assistance and would have to wait to have incontinence briefs changed or receive assistance to go to the bathroom. Records review revealed the overnight (NOC) schedule was a total of four (4) staff, one (1) staff was scheduled for the NOC assisted living floor and three (3) staff were scheduled for the NOC memory care floor.

Continued on LIC9099-C page.

SUPERVISOR'S NAME: Alexandre Vo	TELEPHONE: (619) 385-7506
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20210701162828

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ST. PAUL'S VILLA	FACILITY NUMBER: 370804823
	VISIT DATE: 03/09/2022

NARRATIVE

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Further investigation revealed between one (1) and two (2) positions were consistently unstaffed on the NOC shift. Investigative interviews revealed the NOC shift staff on the assisted living floor was responsible for medication administration, care needs, and responding to call lights for 15 residents. Six (6) of those residents required assistance with toileting and mobility needs between two (2) and three (3) times a night. The Department was unable to interview R1.

Based on the evidence obtained during the investigation, the Department has found that the licensee did not meet the incontinence needs of R1 and did not meet the needs of the residents. Therefore, the allegations are deemed substantiated, which means that the preponderance of the evidence standard has been met and the allegations are valid. The following deficiencies were cited per CA Code of Regulations Title 22 and noted on the attached LIC9099-D page.

An exit interview was conducted with Executive Director LaTressa Downing. A copy of this report and the Licensee Rights (LIC9058 01/16) were provided to Executive Director via email. An electronic receipt of confirmation was requested to be sent by the Executive Director upon receipt of these documents.

SUPERVISOR'S NAME: Alexandre Vo	TELEPHONE: (619) 385-7506
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 08-AS-20210701162828

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ST. PAUL'S VILLA	FACILITY NUMBER: 370804823
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/09/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/30/2022 Section Cited CCR 87625(b)(3)	1 2 3 4 5 6 7	87625 Managed Incontinence (b)(3) … the licensee shall be responsible for… ensuring that incontinent residents are kept clean and dry… This requirement has not been met as evidenced by:	1 2 3 4 5 6 7	Licensee will provide inservice training on call lights and managing incontience. Proof of in-service training to be provided to CCL by POC date.
	8 9 10 11 12 13 14	Based on interviews and record review, the Licensee did not ensure that R1’s incontinence briefs were changed as needed. This posed a potential Health risk to R1.	8 9 10 11 12 13 14
Type B 03/30/2022 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement has not been met as evidenced by:	1 2 3 4 5 6 7	Licensee stated on staff shortage, Licensee will call registry staff to fill positions. A written copy of the staffing policy to be provided to CCL by POC date.
	8 9 10 11 12 13 14	Based on interviews and record review, the Licensee did not ensure the facility was appropriately staffed to meet residents’ needs. This poses a potential Health risk to residents in care.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Alexandre Vo	TELEPHONE: (619) 385-7506
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022

LIC9099 (FAS) - (06/04)

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