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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604063
Report Date: 10/28/2024
Date Signed: 10/28/2024 07:59:13 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
05/23/2024 and conducted by Evaluator Amy Domingo
COMPLAINT CONTROL NUMBER: 08-AS-20240523154148
FACILITY NAME:MESAVIEW SENIOR ASSISTED LIVINGFACILITY NUMBER:
374604063
ADMINISTRATOR:GENOVEVA GUERREROFACILITY TYPE:
740
ADDRESS:7971 CULOWEE STREETTELEPHONE:
(619) 466-0253
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY:30CENSUS: 28DATE:
10/28/2024
UNANNOUNCEDTIME BEGAN:
03:13 PM
MET WITH:Ileana Castro Assistant ManagerTIME COMPLETED:
03:44 PM
ALLEGATION(S):
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Staff are not attending to resident's hygiene needs
INVESTIGATION FINDINGS:
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Licensing Program Manager (LPM) Simon Jacob and Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to deliver findings in the above complaint allegation. LPM and LPA identified themselveself and discussed the purpose of the visit with Ileana Castro Vasquez, Assistant Manager.

On May 23, 2024, Community Care Licensing (CCL) received a complaint alleging that staff are not attending to resident's hygiene needs. During the investigation, LPA Domingo conducted a facility tour, collected pertinent records, and conducted interviews.



(Continued on LIC9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024
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 3
Control Number 08-AS-20240523154148
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: MESAVIEW SENIOR ASSISTED LIVING
FACILITY NUMBER: 374604063
VISIT DATE: 10/28/2024
NARRATIVE
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Continued from LIC9099


It was alleged that  staff are not attending to resident's hygiene needs. Resident 1 (R1), (Please refer to the LIC811 confidential names), who reported to Outside Source 1 (OS1), that on Wednesdays and Thursdays the night shift does not attend to R1's hygiene needs. R1's records were reviewed and the Physician's Report LIC602 documented that R1 was able to make decisions with no cognitive deficits.  R1 was interviewed and R1 stated that only during the month of May 2024, the night time staff did not respond to R1's call light for a request to assist with hygiene needs.  R1 stated that waiting for over an hour was not acceptable.

Outside source 1 (OS1) was interviewed and stated that R1's allegation was reviewed with management and staff and was confirmed to be a valid complaint.  Outside Source 2 (OS2) stated that R1 discussed R1's concerns with the night time staff for the month of May 2024 and OS2 confirmed that staff were not addressing R1's hygiene needs due to the call light system was not functioning. Staff 1 (S1) and Staff 2 (S2) was interviewed and confirmed that R1's complaint of not attending to resident's hygiene needs were valid for the month of May 2024 due to the call light was not working.

Based review of records and interviews a preponderance of evidence exists to support the allegation that staff are not attending to resident's hygiene needs. The allegation is therefore substantiated. A deficiency is cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). An exit interview was conducted with Ileana Castro Assistant Manager, to whom a copy of this report, LIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to Ileana Castro Assistant Manager. 
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20240523154148
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: MESAVIEW SENIOR ASSISTED LIVING
FACILITY NUMBER: 374604063
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/27/2024
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 vendor 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 and completed to CCLD by 11/27/2024.
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Based on record review and interviews, Licensee did not provide basic services, as specified in Section 87457, for 1 of 28 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: Amy Domingo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3