371881440-10-10-2023-18-AS-RSTS-CWVTXU-20231023150742

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 371881440
Report Date: 10/10/2023
Date Signed: 10/10/2023 12:16:26 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/05/2023 and conducted by Evaluator Sara Martinez

COMPLAINT CONTROL NUMBER: 18-AS-20230905084729

FACILITY NAME:	ANA'S ELDER CARE		FACILITY NUMBER:	371881440
ADMINISTRATOR:	SIVCEV, KATARINA-NASTASJA		FACILITY TYPE:	740
ADDRESS:	1828 PASEO DEL LAGO DRIVE		TELEPHONE:	(760) 420-0702
CITY:	VISTA	STATE: CA	ZIP CODE:	92081
CAPACITY:	6	CENSUS: 4	DATE:	10/10/2023
		UNANNOUNCED	TIME BEGAN:	11:40 AM
MET WITH:	Mey bryan Bugia - Staff		TIME COMPLETED:	12:27 PM

ALLEGATION(S):

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Staff physically abused resident in care resulting in bruising.
Staff verbally abused resident in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced visit to the facility to conclude an investigation regarding the allegations listed above. LPA was granted entry and met with caregiver Mey Bryan Bugia who was informed of the purpose for this visit.

Regarding the allegation "staff physically abused resident in care resulting in bruising", it was alleged that staff had kicked and pushed Resident One (R1) on the floor. R1 was admitted to the facility at approximately 6:00pm on 08/28/2023 and was transported to Scripps Encinitas ER in the early morning of 08/29/2023. R1 was served dinner and was observed to be calm by staff and R1’s responsible party. During the night of 08/28/2023 Staff One (S1) and Licensee stated R1 began to yell and had an aggressive emotional outburst throughout the night. S1 stated R1 began to make rude and threatening remarks to S1 and to the other caregiver working. On the morning of 08/29/2023, R1 refused to take medication, refused help from staff, and was combative. S1 contacted Licensee to inform her of the situation. Licensee contacted the Power of Attorney (POA) and the POA informed Licensee to call 911. When paramedics arrived at the facility on 08/29/2023, it was notated that R1 had bruises on the forehead and under the eyes. *CONTINUED ON LIC9099-C*

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

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 18-AS-20230905084729

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ANA'S ELDER CARE	FACILITY NUMBER: 371881440
	VISIT DATE: 10/10/2023

NARRATIVE

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LPA’s record review of R1’s discharge papers from Tri-City Medical Center on 08/28/2023 at 04:10pm had a diagnosis of a Facial or Scalp Contusion and R1 had a bruise to forehead prior to being admitted to the facility on 08/28/2023. POA confirmed R1 had a bruise on the forehead and under the eyes before being admitted to the facility due to a fall at her previous facility. Based on LPA’s interviews and record review this allegation is unfounded at this time.

Regarding the allegation “Staff verbally abused resident in care” LPA’s interview with POA and record review revealed that R1 has a history of paranoia and making inappropriate comments. POA stated R1 has a history of making accusations of physical abuse from previous caregivers. LPA’s record review of Tri-City Medical Center physician’s report states R1 has been having frequent paranoia due to advancing dementia. POA does not believe staff had verbally abused R1 while in care. Based on the information obtained from interviews and record review there is no evidence to corroborate the allegations of verbal or physical abuse that could have occurred therefore this allegation is UNFOUNDED.

A finding of unfounded means that the allegation(s) was false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted where this report and LIC811 was reviewed and provided to caregiver Bugia.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

LIC9099 (FAS) - (06/04)

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