<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 370804823
Report Date: 06/19/2025
Date Signed: 06/19/2025 02:20:04 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
03/17/2025 and conducted by Evaluator Juliana Barfield
COMPLAINT CONTROL NUMBER: 08-AS-20250317091651
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: 109DATE:
06/19/2025
UNANNOUNCEDTIME BEGAN:
11:54 AM
MET WITH:Nursing Director Divina SalinasTIME COMPLETED:
02:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff mismanaged resident's medication.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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. The Department’s investigation consisted of records reviews and interviews with staff and outside sources.

It was alleged that the staff mismanaged resident’s medication. Based on records reviews and interviews, Resident one (R1) and Resident two (R2) were at the nursing station to receive their medications on 03/13/2025. Medication Technician (Med Tech) had both of their medications separated in different souffle cups held in one hand. Med Tech used the other hand to get water. Med Tech handed R1 medication first, looked down and realized the dispensed medication was for R2. Med Tech told R1, “Wait, don’t take that yet,” and R1 replied that R1 had already taken the medication. Interviews revealed that R1 swallowed R2’s medication. R1 was monitored closely for any adverse signs. All vital signs were normal.



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

DATE: 06/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025
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-20250317091651
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: 06/19/2025
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
The Department has investigated the above-mentioned allegation. Based on records reviews and interviews, the Department has found that a preponderance of evidence exists to support the allegation that staff mismanaged resident’s medication. 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 Divina 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: 06/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20250317091651
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: 06/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/19/2025
Section Cited
CCR
87465(a)(4)
1
2
3
4
5
6
7
A plan for incidental medical and dental care shall be developed by each facility... by compliance with the following: The licensee shall assist residents with self-administered medications as needed.
1
2
3
4
5
6
7
Director of Nursing stated she will train Med Techs with the proper medication process when administering medication to residents. POC was cleared today, 06/19/25 with the submittal of medication training already completed by staff with DON.
8
9
10
11
12
13
14
Based on records reviews and interviews, LPA found there was a preponderance of evidence that supported the allegation of staff mismanaged resident's medication. This allegation is substantiated.
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.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Juliana Barfield
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3