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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374602768
Report Date: 02/01/2023
Date Signed: 02/01/2023 04:04:03 PM

Substantiated


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
03/15/2021 and conducted by Evaluator Daniel Pena
COMPLAINT CONTROL NUMBER: 08-AS-20210315163900
FACILITY NAME:MINDFUL LIVING RCFEFACILITY NUMBER:
374602768
ADMINISTRATOR:AGUILO, ALECANDERFACILITY TYPE:
740
ADDRESS:147 TASMAN PLACETELEPHONE:
(619) 434-7826
CITY:SAN DIEGOSTATE: CAZIP CODE:
92114
CAPACITY:6CENSUS: 2DATE:
02/01/2023
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Alecander Aguilo, AdministratorTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff are not providing basic services to resident in care
Staff are not providing personal hygiene assistance to resident in care
INVESTIGATION FINDINGS:
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On 02/01/2023, at about 11:30 AM, Licensing Program Analyst (LPA) Daniel Pena visited the facility regarding the aforementioned complaint allegations. LPA introduced himself and after displaying his identification was allowed into the facility. LPA met with Licensee, Alecander Aguilo, to whom the elements of this complaint were discussed. During the visit, LPA toured the physical plant, interviewed staff, and discussed the findings of the investigation with Licensee, Aguilo.

On 3/15/2021, the Department received a complaint alleging the following: staff are not meeting resident's needs, not changing resident’s bandage, and not ensuring resident’s hygiene needs are met. The Department’s investigation consisted of facility visits, record reviews and interviews with clients, staff, and outside sources. It was alleged on 3/15/2021, R1 arrived at a medical facility for dialysis treatment. It was alleged R1 was wearing a shirt with a large blood stain near the area the dialysis port would be located. It was reported R1 appeared at dialysis treatment, wearing the same shirt and bandage, at least twice, until dialysis personnel changed the bandage.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Daniel Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023
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 3
Control Number 08-AS-20210315163900
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: MINDFUL LIVING RCFE
FACILITY NUMBER: 374602768
VISIT DATE: 02/01/2023
NARRATIVE
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R1’s medical records were reviewed and indicate, due to their medical condition, R1 receives hemodialysis treatments three times a week. R1 has diabetes, hypothyroidism, atrial fibrillation, hypertension, blind left eye, and depression. R1 ambulates with a walker, uses a wheelchair when going to medical appointments/dialysis, is able to toilet without assistance but requires supervision/assistance with bathing/homemaking tasks.

A review of R1’s shower and clothing changes was conducted. R1’s shower records for March 2021 showed that R1 received shower assistance on March 2,5,9,16,18,21,23 and 28. R1’s hygiene records showed R1 received clothing change and hygiene assistance on March 2,5, 9, 16, 18, 21,23 and 28. LPA interviewed R1 during this investigation. LPA did not observe any signs of neglect or abuse. When asked, R1 told LPA they were doing okay and expressed no concerns with the care and supervision received by staff at the facility. R1 records reflect that they do not have a next of kin nor are they conserved. Client interviews did not bring forth concerns or signs of neglect or abuse.

Outside agencies were contacted and stated that they had not received any related complaints for this facility. Additionally, an outside agency conducted a visit to the facility during this investigation and observed no signs of neglect or abuse to any of the residents.

However, when interviewed, facility staff admitted that they did not change R1's bandage one time. Staff explained that they did not change R1's bandage because they thought it would be changed by dialysis personnel at R1's next visit. However, a review of R1's Needs and Services Plan was shared with staff which showed that facility staff was required to change R1's bandage as needed.

The Department has investigated the allegations that staff are not meeting resident's needs, not changing resident’s clothing and bandages, and not ensuring a resident’s hygiene needs are met. Based on interviews and record reviews obtained during the course of the investigation, the preponderance of evidence standard has been met. The findings are determined to be Substantiated. A deficiency is cited in accordance to the California Code of Regulations, Title 22, Division 6, Chapter 8, and is noted on the attached LIC9099-D. A plan of correction was jointly formulated with Licensee, Aguilo.

An exit interview was conducted with Licensee, Aguilo. A copy of this report along with Licensee/Appeal Rights (LIC 9058 01/16) were provided and Licensee, Aguilo's signature on this form confirms receipt of these reports.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Daniel Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20210315163900
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: MINDFUL LIVING RCFE
FACILITY NUMBER: 374602768
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/02/2023
Section Cited
CCR
87464(d)
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Basic Services. The facility shall be responsible for meeting the resident's needs, as specified in Section 87457, Pre-admission Appraisal and providing the other basic services…This requirement was not met as evidenced by:
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Licensee agreed to arrange training for all staff, specifically related to resident post-dialysis treatment hygiene, clothing and bandage changes. Licensee to forward written proof training has been scheduled to CCLD by 2/2/2023. Training to be completed and sign in sheets forwarded to CCLD by 3/2/2023.
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Based on record review and interviews, Licensee did not provide basic services, as specified in Section 87457, for 1 of 3 residents in care [R1]. This posed a potential health risk to residents in care.
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Type B
02/02/2023
Section Cited
CCR
87464(f)(4)
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Basic Services. Personal assistance and care as needed by the resident…such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608. This requirement was not met as evidenced by:
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Licensee agreed to arrange training for all staff, specifically related to resident post- dialysis treatment hygiene, clothing and bandage changes. Licensee to forward written proof training has been scheduled to CCLD by 2/2/2023. Training to be completed and sign in sheets forwarded to CCLD by 3/2/2023.
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Based on record review and interviews, Licensee did not provide personal assistance, as specified in Section 87464(f)(4), for 1 of 3 residents in care [R1]. This posed a potential health risk to residents in care.
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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: Simon Jacob
LICENSING EVALUATOR NAME: Daniel Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3