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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 372004894
Report Date: 07/07/2023
Date Signed: 07/07/2023 03:14:42 PM

Unsubstantiated


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
08/05/2022 and conducted by Evaluator Amy Domingo
COMPLAINT CONTROL NUMBER: 08-AS-20220805113212
FACILITY NAME:TIERRASANTA VERNANEL CARE HOMEFACILITY NUMBER:
372004894
ADMINISTRATOR:PANAO, NELLY, D.FACILITY TYPE:
740
ADDRESS:11085 ZAGALA COURTTELEPHONE:
(858) 569-1870
CITY:SAN DIEGOSTATE: CAZIP CODE:
92124
CAPACITY:6CENSUS: 2DATE:
07/07/2023
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Nelly D. Panao AdministratorTIME COMPLETED:
01:59 PM
ALLEGATION(S):
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Resident(s) not being treated with dignity.
Resident's personal property was confiscated
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to deliver the finding in the above mention complaint allegations. LPA Domingo identified herself and discussed the purpose of the visit with Licensee Nelly D. Panao.

During the investigation, LPA Domingo collected pertinent resident records as well as facility documentation and conducted interviews with staff, residents and outside sources.

It was alleged that Residents were not being treated with dignity. LPA Domingo interviewed 4 Residents. Resident 1 (R1) through Resident 4 (R4) (See LIC811 Confidential Names list), stated that they all have been treated with dignity. Review of R1 through R4's Physician's report documented the Resident's with mild cognitive deficits. LPA Domingo observations of R1 through R4 concur with the Physician's report. Interview with outside source 1 (OS1) observed staff treating residents with dignity.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023
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-20220805113212
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: TIERRASANTA VERNANEL CARE HOME
FACILITY NUMBER: 372004894
VISIT DATE: 07/07/2023
NARRATIVE
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(Continued from LIC9099)


Interview with outside source 2 (OS2) has only observed staff treating resident's with dignity.

It was alleged that Resident's personal property was confiscated.  LPA Domingo reviewed facility records and verified the Resident's personal property was accounted for and in the possession of the resident.  LPA interviewed R1 regarding personal property and R1 responded that there was no personal property confiscated. LPA Domingo interviewed R2 with no personal property being confiscated. OS1 was interviewed with no knowledge of Residents personal property being confiscated.

Based on LPA's interviews with Residents, outside source interviews, and records reviewed there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegations are unsubstantiated. An exit interview was conducted with Licensee, to whom a copy of this report, and the Licensee Appeal Rights (LIC 9058 03/22) were provided.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2