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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 370804823
Report Date: 03/20/2025
Date Signed: 03/20/2025 05:28:31 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
03/13/2025 and conducted by Evaluator Juliana Barfield
COMPLAINT CONTROL NUMBER: 08-AS-20250313130008
FACILITY NAME:ST. PAUL'S VILLAFACILITY NUMBER:
370804823
ADMINISTRATOR:ELEANOR DOWNINGFACILITY TYPE:
740
ADDRESS:2340 FOURTH AVENUETELEPHONE:
(619) 232-2996
CITY:SAN DIEGOSTATE: CAZIP CODE:
92101
CAPACITY:200CENSUS: 107DATE:
03/20/2025
UNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Director of Nursing Divina SalinasTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Staff did not ensure that resident was adminstered their medication as prescribed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Juliana Barfield conducted an unannounced complaint visit regarding the above-mentioned allegation. LPA was met by, identified herself to, and discussed the purpose of the visit with Nursing Director Divina Salinas. LPA and Ms.Salinas briefly toured the facility.

The Department's investigation consisted of record review and interviews with outside sources and staff. It was alleged that the facility staff did not ensure that a resident was adminstered their medication as prescribed.

A resident was prescribed a course of medication for five days however, the staff input an incorrect time for the receipt of the medication into their electronic medication administration system. This resulted in the wrong dose being given to the resident on the first day of administration. No dose of medication was given on the second day. The correct dose was given on the third day before the staff became aware that the the overall administation course of the medication was incorrect.

(Continued on 9099-C page)





Substantiated
Estimated Days of Completion: 1
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Juliana Barfield
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025
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-20250313130008
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: ST. PAUL'S VILLA
FACILITY NUMBER: 370804823
VISIT DATE: 03/20/2025
NARRATIVE
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(Continued from LIC9099-C)

LPA’s record review and interviews confirmed that the resident was not administered their medication as prescribed in regards to the proper time and in the correct dosage.

The Department has investigated the above-mentioned allegation and has found that a preponderance of evidence exists to support the allegation. Therefore, the allegation is deemed substantiated.

One deficiency is cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D).

An exit interview was conducted with Ms. Salinas, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided during the visit.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Juliana Barfield
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20250313130008
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ST. PAUL'S VILLA
FACILITY NUMBER: 370804823
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/20/2025
Section Cited
CCR
87465(a)(4)
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A plan for incidental medical and dental care shall be developed...The plan shall encourage routine medical and dental care and provide for assistance...by compliance with the following: The licensee shall assist residents with self-administered medications as needed.
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Director of Nursing stated she created an Antibiotic Login Sheet and trained LVNs and Med Techs on it's use. DON also reviewed the proper inputting of prescriptions into the electronic MAR system. Confirmation of training with employee signatures is due to licensing by POC date 04/03/2025.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Juliana Barfield
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3