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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603836
Report Date: 04/19/2021
Date Signed: 04/19/2021 03:27:00 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
04/16/2020 and conducted by Evaluator Lizzette Tellez
COMPLAINT CONTROL NUMBER: 08-AS-20200416135945
FACILITY NAME:SENIORS DIGNITY HOME AND CAREFACILITY NUMBER:
374603836
ADMINISTRATOR:ALOZIE, EDWARDFACILITY TYPE:
740
ADDRESS:966 BOLLENBACHER STREETTELEPHONE:
(619) 957-6133
CITY:SAN DIEGOSTATE: CAZIP CODE:
92114
CAPACITY:6CENSUS: 6DATE:
04/19/2021
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Licensee/Administrator, Edward AlozieTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Resident has no access to a functioning toilet
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Lizzette Tellez contacted the facility via telephone to deliver findings for a complaint investigation due to COVID-19. LPA identified herself and discussed the purpose of the call with Administrator, Edward Alozie.

Investigation consisted of interviews with staff, outside sources, review of records, and a tour of the facility. It was alleged that Resident #1 (R1) did not have access to a functioning toilet. Mr. Alozie was provided with Confidential Names Form in order to identify R1. Investigation revealed that on the evening of March 30, 2020, R1 was admitted to the facility. Staff provided R1 with a urinal and commode bucket to relieve themselves, as opposed to using one of the three functioning toilets in the facility. Record review revealed that R1 was ambulatory and did not require assistance when going to or using the bathroom. The Department was unable to interview R1. Interview with credible outside sources who had spoken to R1 supported the allegation. During a tour of the facility, LPA observed a urinal and bucket in a R1’s bedroom. The Department has investigated the allegation that R1 did not have access to a functioning toilet and has found that, based upon interviews and record review, the preponderance of the evidence standard has been met. Therefore, this allegation is deemed substantiated.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Lizzette Tellez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2021
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
04/16/2020 and conducted by Evaluator Lizzette Tellez
COMPLAINT CONTROL NUMBER: 08-AS-20200416135945

FACILITY NAME:SENIORS DIGNITY HOME AND CAREFACILITY NUMBER:
374603836
ADMINISTRATOR:ALOZIE, EDWARDFACILITY TYPE:
740
ADDRESS:966 BOLLENBACHER STREETTELEPHONE:
(619) 957-6133
CITY:SAN DIEGOSTATE: CAZIP CODE:
92114
CAPACITY:6CENSUS: 6DATE:
04/19/2021
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Licensee/Administrator, Edward AlozieTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Resident is not receiving medications
Resident is not being adequately fed
Staff yelled at resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Lizzette Tellez contacted the facility via telephone to deliver findings for a complaint investigation due to COVID-19. LPA identified herself and discussed the purpose of the call with Administrator, Edward Alozie.

Investigation consisted of interviews with staff, outside sources, residents, review of records, and a tour of the facility. It was alleged that Resident #1 (R1) did not receive medications. Mr. Alozie was provided with Confidential Names Form in order to identify R1. Investigation revealed that R1 arrived to the facility on the evening of March 30, 2020. R1 arrived with prescribed medications to be given at scheduled intervals. Interview with staff revealed that R1 was medication compliant and had not refused medications. R1’s medications were observed to be centrally stored and secured. Medications on hand were reviewed and no discrepancies were found. The Department was unable to interview R1.


Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Lizzette Tellez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 08-AS-20200416135945
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: SENIORS DIGNITY HOME AND CARE
FACILITY NUMBER: 374603836
VISIT DATE: 04/19/2021
NARRATIVE
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It was alleged that R1 was not adequately fed. Interviews with staff revealed that the facility provides three meals per day along with snacks. Staff attempt to provide foods that residents request. Interviews with outside sources did not support the allegation. A tour of the facility was conducted, and a varied and ample supply of perishable and non-perishable food was observed. Review of R1’s records revealed R1 did not require a special diet and did not require assistance with feeding. The Department was unable to interview R1. Interviews with residents did not support the allegation. Residents stated a varied menu is provided. Meals provided are sufficient to satiate them and snacks are provided. Approximate meal times were within regulation.

It was alleged that Staff #1 (S1) yelled at R1. Interviews with staff and outside sources did not support the allegation. S1 denied having yelled at R1 or other residents. The Department was unable to interview R1. Interviews and LPA observation also revealed that S1 speaks with a naturally loud voice. Outside sources corroborated that there may be misinterpretations, possibly due to cultural differences. S1 affirmed that although they have a loud speaking voice, there is no ill-intent.

The Department has investigated the above-mentioned allegations and has found that based upon interviews, record review, and observations, there is insufficient evidence to corroborate the allegations. Therefore, these allegations are deemed unsubstantiated.

An exit interview was conducted with Mr. Alozie and a copy of this report, along with Licensee Rights (LIC 9058 01/16), were provided to the Administrator via electronic mail. An electronic receipt of confirmation was requested to be sent by the Administrator upon receipt of the documents.
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Lizzette Tellez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 08-AS-20200416135945
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: SENIORS DIGNITY HOME AND CARE
FACILITY NUMBER: 374603836
VISIT DATE: 04/19/2021
NARRATIVE
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This deficiency is noted on the attached 9099-D, and is cited in accordance with the California Code of Regulations, Title 22. An exit interview was conducted with Mr. Alozie and a copy of this report, along with Licensee Rights (LIC 9058 01/16), were provided to the Administrator via electronic mail. An electronic receipt of confirmation was requested to be sent by the Administrator upon receipt of the documents.
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Lizzette Tellez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 08-AS-20200416135945
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: SENIORS DIGNITY HOME AND CARE
FACILITY NUMBER: 374603836
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/26/2021
Section Cited
CCR
87468.1(a)(3)
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PERSONAL RIGHTS OF RESIDENTS IN ALL FACILITIES
To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.
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Licensee stated that upon arrival, residents will be shown to the nearest functioning toilet for their convenience. Additionally, personal rights training will be provided to all staff, and proof of training will be provided to CCL by 4/26/21.
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This requirement was not met as evidenced by:
Based on interviews, record review, and LPA observations, upon arrival to the facility, staff did not allow R1 access to a functioning toilet. This posed a potential personal rights risk to R1.
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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: John Rante
LICENSING EVALUATOR NAME: Lizzette Tellez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5