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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603746
Report Date: 08/16/2024
Date Signed: 08/16/2024 12:02:27 PM

Substantiated


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
11/28/2022 and conducted by Evaluator Tiffany Holmes
COMPLAINT CONTROL NUMBER: 08-AS-20221128083012
FACILITY NAME:CHHINA'S SENIOR GUEST HOUSEFACILITY NUMBER:
374603746
ADMINISTRATOR:CHHINA, JIWAN SFACILITY TYPE:
740
ADDRESS:8632 SPRING VISTA WAYTELEPHONE:
(619) 337-5201
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY:6CENSUS: 5DATE:
08/16/2024
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Suki Chhina, StaffTIME COMPLETED:
12:05 PM
ALLEGATION(S):
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Centrally stored medications were accessible to residents.
Facility used full bed rails for a non-hospice resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced visit to the facility to conclude a complaint investigation. LPA identified herself and discussed the purpose of the visit and the elements of the allegations with Suki Chhina, Staff.
The Department’s investigation consisted of staff, resident, and outside source interviews and a record review.

It was alleged that centrally stored medications were accessible to residents.
Interviews revealed and LPA observations on December 6, 2022 revealed an unlocked mini refrigerator behind the dining table in the kitchen that held medication unlocked. Interviews and observations revealed there was also medications on the dining room table that belonged to staff and residents.


Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2024
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 4
Control Number 08-AS-20221128083012
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: CHHINA'S SENIOR GUEST HOUSE
FACILITY NUMBER: 374603746
VISIT DATE: 08/16/2024
NARRATIVE
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Interviews revealed that staff was asked to put the medications away from an outside source and they did not do it.

It was alleged that facility used full bed rails for a non-hospice resident. Interviews and prior LPA observations that took place on December 6, 2022 revealed they have a Doctors Order for full bed rails for room 6. Interviews revealed that the bed in room 4 had bed rails but they do not use the bedrails, interviews revealed they just haven't taken them off since the resident moved in back in 2019. Interview revealed that in room 5 they have half bed rails, in room 2 a bed with full bed rails, and room 3 had full bed rails; however, they were on Hospice.

Based on evidence obtained, the allegations are substantiated because the preponderance of the evidence standard has been met. Deficiencies are being cited in accordance with the California Code of Regulations, Title 22, Division 6 Chapter 8, and listed on the 9099D.

An exit interview was conducted with Licensee and a copy of this report, LIC 9099D and Licensee/Appeals Rights (LIC 9058 03/22) were provided. Licensee signature below confirms receipt of the documents.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
11/28/2022 and conducted by Evaluator Tiffany Holmes
COMPLAINT CONTROL NUMBER: 08-AS-20221128083012

FACILITY NAME:CHHINA'S SENIOR GUEST HOUSEFACILITY NUMBER:
374603746
ADMINISTRATOR:CHHINA, JIWAN SFACILITY TYPE:
740
ADDRESS:8632 SPRING VISTA WAYTELEPHONE:
(619) 337-5201
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY:6CENSUS: 5DATE:
08/16/2024
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Suki Chhina, StaffTIME COMPLETED:
12:05 PM
ALLEGATION(S):
1
2
3
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5
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9
Licensee did not provide a comfortable temperature for residents.
Facility was malodorous.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced visit to the facility to conclude a complaint investigation. LPA identified herself and discussed the purpose of the visit and the elements of the allegations with Licensee Chhina.

The Department’s investigation consisted of staff, resident, and outside source interviews. It was alleged that the licensee did not provide a comfortable temperature for residents and that the facility was malodorous. Interviews and LPA observation on December 6, 2022 revealed that there are portable heaters and multiple thick blankets in the outdoor shed for resident use. LPA observed on that day for the thermostat to read 71 degrees Fahrenheit. On the same day the prior LPA toured through the facility and did not smell the facility to be malodorous. Interviews revealed that staff will turn up or down the heat/air if the residents suggests a change. LPA observations for todays visit the thermostat read 71.

Based on evidence obtained, the allegations are unsubstantiated.

An exit interview was conducted with Licensee and a copy of this report and Licensee/Appeals Rights (LIC 9058 03/22) were provided. Licensee signature below confirms receipt of the documents.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 08-AS-20221128083012
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: CHHINA'S SENIOR GUEST HOUSE
FACILITY NUMBER: 374603746
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/06/2024
Section Cited
CCR
87465(2)
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Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
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Licensee did not have any medicaitons out on todays visit. Licensee and staff will have medication training and how to properly store medications by an outside source POC due to CCL by 09/06/2024. Licensee will submit sign in sheet & tranining documents by 09/06/2024
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Based on prior LPA observations and outside witness interviews. the licensee did not ensure medications were inaccessible to 5 out of 5 [R1-R5] persons in care this poses an immediate health and safety risk to residents in care.
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Type B
09/06/2024
Section Cited
CCR
87608
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B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by:
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Licensee does not have any bed rails on beds at this time except for 1.
Licensee and staff will attend a Postural Support training. Proof of training due by POC due date 09/06/2024
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Based on prior LPA observation, the licensee did not comply with the section cited above in 1 out of 5 (R1) residents did not have a hospice care plan that specified a full bed rail was needed or an approval from the Department which posed a potential personal rights risk to persons 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: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4