374603802-3-28-2025-08-AS-SJAB-DFTSWP-20250417141437

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603802
Report Date: 03/28/2025
Date Signed: 03/28/2025 01:23:41 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
03/18/2025 and conducted by Evaluator Amy Rodgers

COMPLAINT CONTROL NUMBER: 08-AS-20250318100259

FACILITY NAME:	RIGHT CHOICE SENIOR LIVING UNIVERSITY CITY		FACILITY NUMBER:	374603802
ADMINISTRATOR:	BROOKS, TODD		FACILITY TYPE:	740
ADDRESS:	6749 RADCLIFFE DRIVE		TELEPHONE:	(619) 246-2003
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92122
CAPACITY:	6	CENSUS: 5	DATE:	03/28/2025
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Administrator Todd Brooks		TIME COMPLETED:	01:35 PM

ALLEGATION(S):

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Staff used full bed rails for non-hospice resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to investigate a complaint. LPA introduced herself, was granted entry into the facility, and met with caregiver, George Barjas, to whom she disclosed the reason for the visit. Administrator Todd Brooks later joined the visit.

It was reported to Community Care Licensing (CCL) on March 18, 2025, that Staff used full bed rails for a non-hospice resident. More specifically, resident #1 (R1) had a full bed rail on one side of his bed, while the other side was positioned against the wall, and there were concerns that the staff might be attempting to restrain R1 with the rails due to behavior issues. [LIC 811 Confidential Names List to identify Resident #1]

The Department’s investigation consisted of staff and client interviews, record reviews, investigative observation, and outside source interviews. (continued on 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20250318100259

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: RIGHT CHOICE SENIOR LIVING UNIVERSITY CITY	FACILITY NUMBER: 374603802
	VISIT DATE: 03/28/2025

NARRATIVE

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(continued form 9099)
According to R1’s LIC602 Physician’s Report, R1 was diagnosed with a cerebral infarction affecting the left non-dominant side as well as dementia. The admissions agreement, as well as the Hospital Discharge documents, indicate R1 has a history of falling. Interviews with staff indicate R1 prefers the left knee to be bent and leaned over against a solid surface.

During today's visit, LPA Rodgers observed full bed rails on R1's bed. LPA observed four other residents beds with no full bed rails. Interviews and records review revealed that 1 of 5 residents are on hospice and 1 hospice resident (R1) has an physicians orders for full bed rails with a care plan dated 3/19/2025. Interviews and LPA observations revealed that R1 is capable of moving around in bed but prefers lying down with his left leg pressed up against a solid surface. Interviews revealed that the full bed rails are used to prevent the residents from falling during the day and night when R1 is sleeping.

Interviews with staff reveal staff they picked up R1's bed from R1's previous facility and used the bed from 3/3/2025 to 3/18/2025. Interviews with outside source and staff conflict as to whether R1 had full bed rails from 3/3/2025 to 3/18/2025. However, LPA observed R1 old bed stored in the garage. The bed stored in the garage did not have full bed rails and Interviews with staff describe that was the bed R1 was using from 3/3/2025 to 3/18/2025.

Interviews with staff and other Resident #2(R2), R1 roommate, do not describe behaviors that would lead R1 to attempting to leave the bed unattended. Staff #1 describes behaviors when trying to attend to incontinence needs for R1 but no other time. The hospital transfer document(dated 3/5/2025) and the Physician's report do not indicate behaviors that would lead R1 to trying to get out of bed unattended.

The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of the evidence has not been met, therefore, this allegation is deemed UNSUBSTANTIATED.

An exit interview was conducted with Administrator Todd Brooks and the care giver George Bajara. A copy of this report was provided and their signature on this report confirms receipt.

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2025

LIC9099 (FAS) - (06/04)

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