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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603665
Report Date: 05/31/2024
Date Signed: 05/31/2024 02:03:06 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/18/2021 and conducted by Evaluator Carmen Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20210618114156
FACILITY NAME:DEVON PLACE HOME CAREFACILITY NUMBER:
374603665
ADMINISTRATOR:MARK LOOFACILITY TYPE:
740
ADDRESS:1814 DEVON PLACETELEPHONE:
(760) 941-1818
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY:6CENSUS: 6DATE:
05/31/2024
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Nestor Blay and Edmund De la Calzada, CaregiversTIME COMPLETED:
02:10 PM
ALLEGATION(S):
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- Resident sustained a stage 4 pressure injury while in care
- Staff handled resident(s) in a rough manner
- Staff did not transfer residents safely resulting in injuries
- Staff are not able to communicate with residents
- Staff did not meet the resident’s hygiene needs
- Staff do not have medication training
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegations. LPA identified herself and was granted entry by caregiver Edmund De la Calzada. LPA stated the purpose of the visit and reviewed the findings of the complaint with caregiver Nestor Blay.

The Department’s investigation consisted of interviews with staff and outside sources, records review of relevant documents pertinent to this investigation, and the Departments. On June 18, 2021, it was alleged that the a resident sustained a stage 4 pressure injury while in care; staff handled resident in a rough manner; staff did not transfer resident safely resulting in injuries; staff are unable to communicate with residents; staff did not meet resident’s hygiene needs; and staff do not have medication training.

Records revealed that R1 had multiple falls and sustained fractures prior to being admitted to the facility. According to records, R1 had already been admitted to hospice prior to facility admission.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024
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 8
Control Number 08-AS-20210618114156
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: DEVON PLACE HOME CARE
FACILITY NUMBER: 374603665
VISIT DATE: 05/31/2024
NARRATIVE
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(Continuation of LIC9099)
Additional records revealed that R1 had sustained falls at their residence prior to hospice and facility admission. Records showed that R1 had diagnosis’ that would place them at risk for injuries.

It was alleged that resident #1 (R1) sustained a stage 4 pressure injury due to staff being neglectful, not repositioning the resident and kept changing the bandage. Interviews with staff said they would reposition the resident, but the resident would never stay in the positions that either staff or their care agency would place R1 in. According to Administrator Rafols, the care agency had informed them, on 05/17/2021, that R1 was being provided wound care. The Administrator said that they provided wound care daily for R1. The care agency had instructed staff to dry, clean and reposition R1 every two hours which staff adhered to. According to Administrator Rafols, at night staff would also conduct their checks every two hours. Interview was conducted with an outside source who confirmed that the facility personnel followed instructions provided by R1s care agency. Per the outside source, R1 was at risk for skin breakdown from the beginning due to poor intake of food, lack of mobility, age, underlining medical conditions and repositioning self-back to the same position after being repositioned to an alternate position by facility staff and R1’s caring agency. This continued when R1 obtained the injury which did not allow the injury to breathe. Staff kept the bandage dry and clean as indicated by the care agency. According to the outside source, there was no evidence to prove that personnel were neglectful while caring for R1 or any other residents. Based on the information obtained there is insufficient evidence to support the allegation.

It was alleged that staff #1 (S1) handled R1 in a rough manner pushing R1 against a railing. Interview with S1 said that they started to volunteer on 6/03/2021. According to S1, they denied hurting R1. R1 left 06/03/2021. S1 said that they and S2 would care for R1. According to Licensee, there was never a time where a family disclosed that a caregiver was rough with a resident nor a resident obtaining an injury due to staff. Interview with an outside source said that they had no issues with the staff at the facility. They were continuously there assisting R1 and saw that the staff were accommodating with the care they provided to them. There were no records to show that there were any incidents reported to the Regional Office by the facility or a third-party agency to indicate that R1 was being mishandled. Based on the information obtained, there is insufficient evidence to support the allegation.
(Continuation of LIC9099-C)
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 08-AS-20210618114156
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: DEVON PLACE HOME CARE
FACILITY NUMBER: 374603665
VISIT DATE: 05/31/2024
NARRATIVE
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(Continuation of LIC9099-C)
It was alleged that the facility staff attempted to transfer R1 from their bed resulting in R1 falling and sustaining injury to their leg and toes. Interviews with S1 and S2 they did not witness R1 falling. They did witness R1 placing their legs between their railings and at times attempt to get out of bed. Due to this, R1s care agency placed pads on the railings to prevent this from occurring. This assisted with preventing R1 placing their legs between the railings. This was confirmed by R1s care agency. According to staff, R1 stopped placing their legs on the railings once their care agency placed the pads on the railings. It should be noted that during the interview with RP, they did not specifically indicate any neglect when dealing with R1s care, only that S1 scraped their leg and toes and R1 was not transported to the hospital. During an interview with the outside care agency, they did not have any issues with the care provided by the facility staff. Based on the information obtained, there is insufficient evidence to support the allegation.

It was alleged that S1 had a communication barrier with residents as they did not speak English. An interview was conducted with S1 who said that they and S2 provided care to R1. According to S2 the family visited R1 daily and R1s care agency came almost every morning. Administrator and Licensee were shocked to find that RP was moving R1 unexpectedly from the facility. They were unaware if there were issues with the services provided by the facility. According to Licensee, his caregivers have been able to communicate with the residents and the family’s. They do speak English but acknowledged that there may be times where a family may not understand what a caregiver may say but they have been able to schedule at least two caregivers one who is able to communicate with the residents and families, along with the Administrator who often go to the facility. According to the care agency, they had no issues with communicating the care needs of R1 to staff. They were able to educate the staff at the facility and the staff was able to comprehend the services that were required for R1s care. According to a letter directed to Licensee from RP, the letter did not indicate issues with staff not being able to communicate with residents. The letter demonstrated that there were personal matters that led to the removal of R1 from the facility. During a visit on 05/01/2024, LPA observed that current staff did speak enough English to be able to communicate with the residents. LPA was able to interview staff and obtain statements. Based on the information obtained, there is insufficient evidence to support the allegation that staff were unable to communicate with residents.

It was alleged that on an unknown date, R1 had dried vomit on their shirt and staff did not notice it nor changed them. Staff who formerly worked at the facility were not present during a subsequent visit conducted by LPA on 05/01/24.
(Continuation on LIC9099-C)
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 08-AS-20210618114156
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: DEVON PLACE HOME CARE
FACILITY NUMBER: 374603665
VISIT DATE: 05/31/2024
NARRATIVE
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(Continuation of LIC9099)
LPA attempted to make contact with a former employee for interview to no avail. Current staff interviewed and they said that residents are usually showered about three times per week unless they are declining a shower. If a resident is on hospice, the hospice agency provides showers twice per week. At times residents only want to do bed baths which they provide but in these cases, CNA would conduct bed baths daily. According to the licensee, the caregivers have been able bathed residents about four times per week depending on the care plan of the resident and the residents and family’s wants and needs. There are some residents who bathe daily and other who bathe about every other day. He mentioned that he does not tolerate for staff to neglect residents’ hygiene. According to the Licensee, there have not been any families who have brought hygiene to his attention. Interview with an outside source, mentioned that every time they saw R1, they were well groomed and had been clean and dry. The only time they saw R1 somewhat oily was when R1 was feverish. They had no issues with R1’s hygiene. They would see R1 at least every other day if not more often. Based on the information obtained, there is insufficient evidence to support the allegation.

It was alleged that staff were not trained to administer medication. According to the licensee, when staff are initially hired, they have a log for their 30-day requirements and medication training is included as a part of the initial training course. The initial medication training is provided by the licensee and the administrator. They licensee uses training material obtained during their Administrator’s course. He uses the book to provide caregivers insight of how to administer medications and includes how to audit medications. He also uses videos and hands on training for the caregivers. According to the licensee, he also has the Hospice Agency and/or Home Health Agency to give caregivers additional training yearly or on an as needed basis. R1s care agency confirmed that the Hospice agency for R1 provided caregivers medication training along with other care needs for R1. There were no issues with the medication annotated by R1s care agency regarding their medication. According to staff training records staff in 2021 received one hour of medication policies/ procedures training between 6/02-03/2021; and .50 hours of medications that are self-administered between 6/04-05/2021. According to a professional outside source, they went over R1s medication at every visit and staff were on the same page regarding resident’s care. Based on the information obtained, there is insufficient evidence to support the allegation.

(Continuation on LIC9099-C)
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 08-AS-20210618114156
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: DEVON PLACE HOME CARE
FACILITY NUMBER: 374603665
VISIT DATE: 05/31/2024
NARRATIVE
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(Continuation of LIC9099-C)

Based on the Department’s investigation of the above-mentioned allegations and the evidence obtained during staff and outside sources interviews, records reviewed, and LPA observations, there is insufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegations are deemed to be unsubstantiated.

The report was discussed, and an exit interview was conducted with Licensee Mark Loo and Administrator Sherryl Rafols. A copy of this report along with Licensee/Appeal Rights (LIC9058 01/16) were provided to licensee at the conclusion of the visit. The signature below confirms the documents were received.
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/18/2021 and conducted by Evaluator Carmen Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20210618114156

FACILITY NAME:DEVON PLACE HOME CAREFACILITY NUMBER:
374603665
ADMINISTRATOR:MARK LOOFACILITY TYPE:
740
ADDRESS:1814 DEVON PLACETELEPHONE:
(760) 941-1818
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY:6CENSUS: 6DATE:
05/31/2024
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Nestor Blay and Edmund De la Calzada, CaregiversTIME COMPLETED:
02:10 PM
ALLEGATION(S):
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- Licensee did not adhere to the Admission Agreement.
- Staff did not provide residents with quality of food.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegations. LPA identified herself and was granted entry by Edmund De la Calzada. LPA stated the purpose of the visit and reviewed the findings of the complaint with caregivers Nestor Blay and Edmund. LPA spoke with Licensee Mark Loo via telephone and informed him of the visit.

The Department’s investigation consisted of interviews with staff and outside sources, and records review of relevant documents pertinent to this investigation. On June 18, 2021, it was said that staff did not provide residents with quality of food; and Licensee did not adhere to the admission agreement.

It was said that RP paid for R1s monthly payment for the month of June 2021 and were not reimbursed for the remaining days after R1 left the facility with their belongings. As to the current year, 2024, the refund has yet to be paid.

(Continuation on LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 08-AS-20210618114156
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: DEVON PLACE HOME CARE
FACILITY NUMBER: 374603665
VISIT DATE: 05/31/2024
NARRATIVE
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According to staff, Administrator and R1’s care agency, R1 left the facility on June 12, 2021. Upon the initial interviews with the Licensee and the Administrator conducted during 2021, the resident was taken from the facility along with their belongings on June 12, 2021. According to the Admission Agreement, R1 moved into the facility on May 1, 2021, and was charged the prorated monthly admission rate with no extra fees being charged. During the visit on 05/01/2024, Licensee confirmed that they did not provide R1 or the family a refund upon their departure as they were unaware, they had to refund them. Based on the information obtained there is sufficient evidence to support the allegation.

It was said that the facility had spoiled milk in the refrigerator and the refrigerator was dirty. According to Licensee, and the Administrator are the ones who do the grocery shopping for the facility and ensure that they have sufficient groceries. As far as the licensee was aware, the staff go through the refrigerator at least weekly to ensure there are no spoiled items in the refrigerator. They were not aware that there were any items kept that were spoiled in the refrigerator. As far as dietary needs, the licensee said that they follow residents’ dietary needs if they have a controlled diet. Although they have a general meal plan on the refrigerator door, licensee said that caregivers consult with the residents to inquire what they prefer to eat in an attempt to cater to the residents. During an interview with the outside care agency, they said that the staff acclimated with the diet orders that they left for R1 and had no additional information to provide. During the initial visit conducted on 6/22/21, the refrigerator did have ample food supply and did not appear unclean. LPA did observe that there were outdated chocolate and regular milk cartons that were about 9 days past the date of expiration. During a visit conducted by LPA on 5/01/2024, LPA observed that there were expired food items in the cupboard and in the refrigerator. The poultry in the refrigerator was 13 days old that needed to be used or frozen by 04/18/24. The poultry was browning in the side areas. According to staff they recently within the last 24-hours taken out. During this same visit, the pantry did have canned food items that has expired in December 2023. Based on the information obtained during the investigation, and LPA’s observations, there is sufficient evidence to support the allegation.

Based on the Department’s investigation of the above-mentioned allegations and the evidence obtained during staff and outside sources interviews and records reviewed, there is sufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegations are deemed to be substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC9099-D.

The report was discussed, plan of correction was jointly developed, and an exit interview was conducted with caregivers Nestor Blay and Edmund De la Calzada. A copy of this report along with Licensee/Appeal Rights (LIC9058 01/16) were provided to caregiver Blay at the conclusion of the visit. The signature below confirms the documents were received.
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 08-AS-20210618114156
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: DEVON PLACE HOME CARE
FACILITY NUMBER: 374603665
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/31/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/14/2024
Section Cited
CCR
87555(a)
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87555 (a) General Food Service Requirements - (a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner… this requirement was not met as evidenced by:
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The facility staff will be discarding the outdated food items from the refrigerator/freezer and cabinets and send LPA an email for a visit by POC due date, 06/14/2024.
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Based on two separate LPA observations, the Licensee did not comply with the section cited above in 5 out of 5 residents were being provided expired food which posed a potential health risk to 5 of 5 of residents in care.
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Type B
06/14/2024
Section Cited
CCR
87468.2
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87468.2 (a)(8) Additional Personal Rights of Residents in Privately Operated Facilities - To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse… this requirement was not met as evidenced by:
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The Licensee will be refunding R1s family the allowance of $2,700 that was owed and submit the check receipt and the mailing receipt by POC due date, 06/14/2024.
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Based on interviews and records review, the Licensee did not comply with the section cited above in 1 out of 1 resident was not refunded their allotted prepaid monthly fee’s which posed a potential personal rights risk to one of X of 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: Jennifer Lott
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024
LIC9099 (FAS) - (06/04)
Page: 8 of 8