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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604273
Report Date: 04/04/2025
Date Signed: 04/04/2025 12:20:00 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
07/21/2021 and conducted by Evaluator Amy Rodgers
COMPLAINT CONTROL NUMBER: 08-AS-20210721101943
FACILITY NAME:CASA MAHALFACILITY NUMBER:
374604273
ADMINISTRATOR:FRAZIER, THERESAFACILITY TYPE:
740
ADDRESS:12631 CASA AVENIDATELEPHONE:
(858) 924-1136
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY:6CENSUS: 5DATE:
04/04/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH: Teresita Duclayan, care giverTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Facility staff is sleeping during shift.
Licensee did not follow universal precautions.
INVESTIGATION FINDINGS:
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**This is an amended report***
Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to deliver findings regarding the above-mentioned allegations. LPA was welcomed by, identified themselves to, and discussed the purpose of their visit with Care GIver Teresita Duelayan. LPA Rodgers called Licensee Myrna Arecleo upon arrival to inform them of LPA Rodgers' presence and purpose in the facility, but they decided not to join the visit.

On July 21, 2021, Community Care Licensing (CCL) received a complaint alleging that staff are sleeping during shift and the Licensee did not follow universal precautions. More specifically, staff had been seen sleeping in the chair while they were on shift in the facility, and for a period of time in July 2021, no symptom screening was conducted, temperature was not checked, and staff were not wearing any face covering. The Department’s investigation consisted of an unannounced facility visit, interviews with facility staff, outside sources, and a records review. (Continued on 9099-c)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2025
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-20210721101943
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: CASA MAHAL
FACILITY NUMBER: 374604273
VISIT DATE: 04/04/2025
NARRATIVE
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(Continued on 9099-C) ***This is an amended report**
Staff was able to produce limited resident files upon CCLD’s request on October 24, 2024. The Licensee replied that they had destroyed most of the six resident records requested by CCLD. The licensee is required to maintain a resident's file for three (3) years after their move-out (which occurred in July of 2021).

Regarding the allegation that the facility staff are sleeping at night.   Staff interviews did reveal staff would occasionally sleep at night in the common room; however,  Staff 1 (S1) indicated when on duty, they would wake up every 2-3 hours to meet incontinence needs and check on residents. The S1 interview revealed that on more than one occasion, they would sleep at the house and wake to find Staff #2 (S2) asleep during the night shift, and attempt to wake S2 many times unsuccessfully. Outside source interviews reveal they have witnessed (S2)  sleeping in a chair while on shift.  According to the record review, there was at least one resident with a diagnosis of dementia at the facility. According to Interviews with staff, there was at least one resident with a diagnosis of dementia and wandering behavior. Therefore, there should be at least one night staff person awake and on duty to supervise.

It was also alleged that the Licensee did not follow universal precautions.  CCLD interviews conducted with staff on July 27, 2021, reveal there were times that staff had to retrain on universal precautions. Staff interviews also revealed that all staff believed that staff did not have to wear masks because everyone was vaccinated. Additionally, staff revealed that no symptom screening was conducted during a period of approximately two months (June and July 2021), and some staff members did not wear masks for about a week or two during the same time period.  An outside source also confirms that in the month of July 2021, the licensee's staff's universal precautions were not followed.  Interviews conducted on October 24, 2024, reveal that staff were not able to recall following specific universal protocol precautions. Additionally, staff training logs for the Summer of 2021 could not be located.

Based on relevant interviews and records review, the preponderance of evidence has been met that the alleged violation occurred and is therefore substantiated. Deficiency is cited per California Code of Regulations, Title 22 (refer to the attached LIC9099-D pages ). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Licensee Arcelao, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided. Care Giver Teresita Duclayan signature below confirms receipt of these documents.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20210721101943
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: CASA MAHAL
FACILITY NUMBER: 374604273
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/09/2025
Section Cited
CCR
87468.1(a)(2)
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Personal Rights of Residents in All Facilities. (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by:
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Administrator offered to conduct in-service training on universal precautionsls with all staff. Administrator offered to provide proof of training to Community Care Licensing by 5/4/2025
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Based on LPA's interviews, licensee did not provide residents with safe and healthful accommodations. This posed a potential health risk to 5 of 5 residents in care.
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Type B
05/09/2025
Section Cited
CCR
87055(b)(2)
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(2) For facilities..ensuring there is at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal,...addition to requirements specified in Section 87415, Night Supervision. This requirement was not met as evidence by:
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Administrator offered to conduct in-service training on night staff requirements with all staff. Administrator offered to provide proof of training to Community Care Licensing by 5/4/2025
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Based on LPA's interviews licensee did not provide residents with safe and healthful accommodations. This posed a potential health risk to 5 of 5 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: Denise Powell
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3