370800558-5-24-2023-08-AS-LTEZ-CSCUSD-20230531155010

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 370800558
Report Date: 05/24/2023
Date Signed: 05/24/2023 03:52:21 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, 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
02/03/2022 and conducted by Evaluator Rebecca A Ruiz

COMPLAINT CONTROL NUMBER: 08-AS-20220203155515

FACILITY NAME:	ST PAUL'S MANOR		FACILITY NUMBER:	370800558
ADMINISTRATOR:	DAMIEN RAPP		FACILITY TYPE:	740
ADDRESS:	2635 SECOND AVE		TELEPHONE:	(619) 239-2097
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92103
CAPACITY:	200	CENSUS: 60	DATE:	05/24/2023
		UNANNOUNCED	TIME BEGAN:	02:50 PM
MET WITH:	Executive Director Timothy Jeffers		TIME COMPLETED:	03:55 PM

ALLEGATION(S):

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Facility is not following COVID-19 guidance

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced complaint visit to conduct follow up and deliver findings regarding the above-mentioned allegation. LPA identified herself to, was greeted by, and explained the purpose of the visit to Executive Director Timothy Jeffers.

During today's visit, LPA observed residents in care and interviewed staff.

The Department’s investigation consisted of interviews with staff and outside sources, records review, and a tour of the facility. It was alleged that the facility was not following COVID-19 guidance, specific to reporting requirements. Records review revealed that in December 2021, the facility had an outbreak of COVID-19 cases. Records review revealed that the Executive Director was in contact with Department staff to report any new COVID-19 cases as they were identified.

Continued on LIC9099-C page...

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023

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 08-AS-20220203155515

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 MANOR	FACILITY NUMBER: 370800558
	VISIT DATE: 05/24/2023

NARRATIVE

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Interviews revealed that when a resident was identified as COVID-19 positive, the Resident Care Director would engage the isolation procedures and would report the COVID cases to the Executive Director. The Executive Director would then prepare a report to the corporate management company who was responsible for reporting any positive COVID-19 cases to the California Department of Public Health (CDPH). Interviews were not able to confirm if the facility’s corporate management team reported all of the COVID-19 cases to the CDPH. Interviews revealed that facility staff were not aware of any attempts by CDPH staff to contact them requesting updates for positive COVID-19 cases.

The Department has investigated the above-mentioned allegation and based on interviews, the preponderance of the evidence has not been met, therefore, this allegation is deemed unsubstantiated.

An exit interview was conducted with Executive Director Timothy Jeffers, to whom a copy of this report and the Licensee Appeal Rights (LIC9058 01/16) were provided via hard copy.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023

LIC9099 (FAS) - (06/04)

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