372004894-4-28-2023-08-AS-SJAB-CSCRZL-20230531132809

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 372004894
Report Date: 04/28/2023
Date Signed: 04/28/2023 04:56:41 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 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
04/25/2023 and conducted by Evaluator Daniel Pena

COMPLAINT CONTROL NUMBER: 08-AS-20230425163347

FACILITY NAME:	TIERRASANTA VERNANEL CARE HOME		FACILITY NUMBER:	372004894
ADMINISTRATOR:	PANAO, NELLY, D.		FACILITY TYPE:	740
ADDRESS:	11085 ZAGALA COURT		TELEPHONE:	(858) 569-1870
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92124
CAPACITY:	6	CENSUS: 4	DATE:	04/28/2023
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Administrator, Nelly Panao		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Due to nelgect, the Licensee did not have supplies necessary to meet resident's care needs

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Daniel Pena conducted an unannounced visit to initiate a complaint investigation. LPA was granted entry after identifying himself. LPA discussed the purpose of the visit and the basic elements of the allegation with Administrator, Nelly Panao.

During the visit, LPA conducted a welfare check of the three present residents, conducted interviews, and obtained copies of records. It was alleged, that due to neglect, the facility did not have a resident’s medical supplies. The investigation consisted of LPA observation, interviews with residents, staff and outside sources and review of facility and resident records.

Interviews with staff and outside sources revealed that on April 24, 2023, Resident 1 (R1) was transported to the hospital Emergency Department. Reportedly, the night prior, R1 was acting out in an unusual manner, yelling and removing their colostomy pouch. An outside source came to the facility to take R1 to the hospital and noticed R1’s colostomy pouch had been removed. In its place was a plastic zip lock bag.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Daniel Pena
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023

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-20230425163347

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: TIERRASANTA VERNANEL CARE HOME	FACILITY NUMBER: 372004894
	VISIT DATE: 04/28/2023

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

The outside source was told by facility staff that they had ordered R1’s ostomy supplies but there was a delay with the supplier.

R1 was transported to the hospital and is still there at the time of this reporting. It was reported that R1’s diagnosed depression increased as a result of the surgical implant of the ostomy. An outside source reported that R1 is at the hospital under evaluation for depression and possible Urinary Tract Infection (UTI). The outside source said the care and supervision provided by facility staff has been satisfactory and they have no problems with R1 returning to the facility after their hospital stay. Interviews with three other residents revealed no complaints related to care and supervision at the facility.

A review of facility and R1’s records contained evidence that the facility did in fact order R1’s ostomy supplies in March 2023 with notes showing several follow up calls made to the supplier due to delayed deliveries. Record reviews also show that facility staff has ordered R1’s ostomy supplies since R1 was first given the appliance in November 2022.

Interviews and records indicate that R1’s ostomy pouches were delivered to the facility on April 24, 2023, after R1 was transported to the hospital. When asked, facility staff said zip lock bags were only used for three days and would not have been used if R1’s supplies were received on time.

The Department has investigated the allegation that due to neglect the facility did not have a resident’s medical supplies. Based upon interviews and record reviews, there is insufficient evidence to support the allegation. Therefore, the Preponderance of Evidence standard was not met, and the finding is Unsubstantiated.

An exit interview was conducted with Administrator Panao and a copy of this report, along with Licensee/Appeal Rights (LIC9058 03/22), were provided.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Daniel Pena
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2