374601329-3-23-2023-08-AS-SJAB-CQ8MKM-20230324094055

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374601329
Report Date: 03/23/2023
Date Signed: 03/23/2023 10:07:04 AM

Substantiated

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
07/15/2022 and conducted by Evaluator Esther Miller

PUBLIC

COMPLAINT CONTROL NUMBER: 08-AS-20220715152459

FACILITY NAME:	GATEWAY GARDENS		FACILITY NUMBER:	374601329
ADMINISTRATOR:	CAMERON AZEMIKHAH		FACILITY TYPE:	740
ADDRESS:	12750 GATEWAY PARK ROAD		TELEPHONE:	(858) 451-9933
CITY:	POWAY	STATE: CA	ZIP CODE:	92064
CAPACITY:	0	CENSUS: 0	DATE:	03/23/2023
		UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Facility closed - Mailed to address on file		TIME COMPLETED:	10:15 AM

ALLEGATION(S):

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Facility did not meet resident's needs.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Esther Miller made a determination of findings and concluded the complaint investigation regarding the above-mentioned allegation. The facility closed on March 7, 2023 due to a change of ownership. This report was mailed to the address on record of the former licensee in order to share the finding.

On July 15, 2022, it was alleged that facility did not meet resident's needs. Specifically, that staff did not meet the needs of Resident 1 (R1) after a fall. The Department’s investigation consisted of interviews with residents, staff, and outside sources, as well as facility and outside source records.

R1 was admitted to the facility on November 12, 2022 and was evaluated to need Level 1 care. Level 1 care was described as “minimum assistance with transfers/toileting/cueing/bathing/dressing/grooming.”

[Continued on LIC9099-C, Page 1 of 2]

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther Miller	TELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023

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 3

Control Number 08-AS-20220715152459

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: GATEWAY GARDENS	FACILITY NUMBER: 374601329
	VISIT DATE: 03/23/2023

NARRATIVE

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Resident appraisal, signed on November 11, 2021, indicated that R1 was a known fall risk. The Level of Care Assessment Tool, conducted on November 8, 2021, indicated “Wellness checks for 24 hours/day.” A handwritten note next to this stated, “4x/Day check – NOC.” R1’s Needs and Service Plan also indicated that R1 was a known fall risk and that facility staff “will provide wellness checks 4x a day for safety.” Physician’s Report also indicated that R1 had dementia.

The facility self-reported to the Department that R1 was found on the floor on June 27, 2022 at around 8:40AM. The report indicated that R1 was last checked on at 11:00PM. Staff interviews indicated that the nocturnal (NOC) shift should check on residents at the beginning of the shift (11:00PM), 1:00AM, and at 3:00AM. The morning shift starts at 6:30AM, in which residents should be checked on again. Facility records and staff interviews indicated that staff did not check on R1 during the night nor at the beginning of the morning shift on June 27, 2022. Staff interviews also revealed that R1 possibly had morning medication that should have been given before they were found. Facility Medication Administration Records could not be obtained to verify claim. Facility records showed three (3) staff on shift the night of June 26, 2022. Interview with staff that provided direct care to R1 was not obtained

Based on the evidence obtained during the complaint investigation, the allegation that facility did not meet resident’s needs is found to be SUBSTANTIATED, as there is a preponderance of evidence to show that the violation occurred. Pursuant to the California Code of Regulations, Title 22, Division 6, deficiency is being cited on the attached LIC9099D. A copy of this report and Licensee's Rights (LIC9058) were mailed to the previous licensee on record.

[Continued from LIC9099, Page 2 of 2]

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther Miller	TELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 08-AS-20220715152459

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: GATEWAY GARDENS	FACILITY NUMBER: 374601329
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/23/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/23/2023 Section Cited CCR 87705(c)(4)	1 2 3 4 5 6 7	Care of Persons with Dementia: (c) Licensees who accept...residents with dementia shall be responsible for ensuring ...: (4) There is...direct care staff to support each resident’s...safety ... needs as identified in...appraisal. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Deficiency cleared due to facility closure on March 7, 2023.
	8 9 10 11 12 13 14	Based on interviews and record reviews, the licensee did not meet resident’s needs which posed a potential safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther Miller	TELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023

LIC9099 (FAS) - (06/04)

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