374603828-2-28-2023-08-AS-IESA-CPH9LD-20230228222745

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603828
Report Date: 02/27/2023
Date Signed: 02/28/2023 08:10:52 AM

Unsubstantiated

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
09/16/2022 and conducted by Evaluator Iby Strong

COMPLAINT CONTROL NUMBER: 08-AS-20220916155210

FACILITY NAME:	A PLACE OF GRACE INC CHASE AVENUE		FACILITY NUMBER:	374603828
ADMINISTRATOR:	SHANTA HAINES		FACILITY TYPE:	735
ADDRESS:	1144 E CHASE AVE		TELEPHONE:	(619) 631-7656
CITY:	EL CAJON	STATE: CA	ZIP CODE:	92020
CAPACITY:	4	CENSUS: 4	DATE:	02/27/2023
		UNANNOUNCED	TIME BEGAN:	02:55 PM
MET WITH:	Direct Support Professional Roberto Rios		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Neglect/lack of supervision resulted in a serious injury requiring hospitalization

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to deliver findings in the above complaint allegation. LPA identified herself and discussed the purpose of the visit with Direct Support Professional Roberto Rios. Interim Adminstrator Mary Meeter arrived shortly after.

On September 16, 2022, Community Care Licensing (CCL) received a complaint alleging staff neglect and/or lack of supervision resulted in serious injury requiring hospitalization. Allegation states that on September 13, 2022, Client 1 was found on the bathroom floor of the facility with a towel wrapped around C1’s legs, C1 was taken to the hospital four hours later where it was found that C1 required a highly invasive surgical procedure. On November 15, 2022, CCL received additional details alleging that C1 was found unconscious at the facility on September 16, 2022, with serious cuts on legs, was admitted to the hospital and later passed away.

Physician’s Report dated September 28, 2021, confirmed C1 was diagnosed with an intellectual disability,

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: John Rante	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Iby Strong	TELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2023

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 2

Control Number 08-AS-20220916155210

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: A PLACE OF GRACE INC CHASE AVENUE	FACILITY NUMBER: 374603828
	VISIT DATE: 02/27/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

schizoaffective disorder, was ambulatory, had bowel and bladder impairment and could occasionally communicate. Individual Program Plan for C1 dated March 15, 2021, revealed that C1 is a conserved adult and required incontinence care reminders every two hours.

During the investigation, through record reviews, and interviews, the Department established the following sequence of events. Based on staff statements, on September 13, 2022, Staff 1 (S1) was conducting a routine incontinence check on C1 at on or about 8:30am when S1 found C1 on the floor of C1’s bedroom. C1 was kneeling on the floor with C1’s blankets wrapped around legs. S1 attempted to assess C1 but did not receive a verbal response and noted a blank stare from C1. S1 observed there was a scratch on top of C1’s foot but legs did not appear swollen. S1 then proceeded to request assistance from S2 who had arrived back at the facility at on or around 8:45am from dropping off other clients at day program. S2 then attempted to verbally prompt C1 with no results, S2 then contacted emergency personnel. Records collected revealed that C1 was admitted to hospital emergency room and examined by a physician by 9:56am on September 13, 2022. According to records collected, C1 did not return to facility after being admitted to hospital for medical treatment.

Hospital records revealed C1 was admitted to the hospital for altered mental status, agitation, lower and upper extremity contraction, and muscle rigidity. Additionally, an outside source medical doctor (MD) reviewed C1’s medical records. According to interview with MD, MD determined that C1 was treated on date of incident for a medication reaction based on symptoms, condition, and medical assessment. Interview also revealed that during treatment it was found that C1 had a pre-existing condition of the liver that ultimately resulted in renal failure. It was determined by records that C1’s conservator decided to terminate dialysis treatment which MD revealed may ultimately lead to death. Additionally, based on C1’s complications during hospital stay, MD stated that such complications could have resulted in pneumonia. According to MD, there was no information on records to determine that C1 was treated for a sustained injury. Records also revealed that there was no apparent evidence to indicate C1 was neglected or physically abused. Outside source interview also revealed that C1’s ultimate cause of death was kidney failure and pneumonia.

Based on a review of pertinent records and interviews, the preponderance of the evidence standard was not met to prove staff neglect and/or lack of supervision resulted in serious injury requiring hospitalization for C1, therefore the allegation is unsubstantiated. An exit interview was conducted with Mary Meeter, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.

SUPERVISOR'S NAME: John Rante	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Iby Strong	TELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2