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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604421
Report Date: 03/01/2023
Date Signed: 03/01/2023 01:32:28 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 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
10/17/2022 and conducted by Evaluator Renita Hall
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20221017083744
FACILITY NAME:LA JOLLA VISTAFACILITY NUMBER:
374604421
ADMINISTRATOR:FERNANDEZ, GUSFACILITY TYPE:
740
ADDRESS:5720 DESERT VIEW DRTELEPHONE:
(858) 775-6935
CITY:LA JOLLASTATE: CAZIP CODE:
92037
CAPACITY:6CENSUS: 2DATE:
03/01/2023
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Kathia Badilla, CaregiverTIME COMPLETED:
01:35 PM
ALLEGATION(S):
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Facility staff dropped residents during transfers
Facility staff did not ensure that resident's bed was properly inflated
Facility staff does not maintain an adequate supply of hygiene products
Facility does not maintain an adequate supply of perishable food
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Renita Hall conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegations. LPA gained access to the facility, identified herself, and met with the caregiver Kathia Badilla to discuss the purpose of the visit.

The Department’s investigation consisted of interviews with staff, residents, outside sources, and review of records.

The allegation that staff dropped residents during transfers has not been corroborated with interviewees. The inflated bed was not part of the Licensee's jurisdiction of responsibility. However, the outside source had been notified and was in the process of replacing the bed.

Continuance on 9099 C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Renita Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023
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 2
Control Number 08-AS-20221017083744
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: LA JOLLA VISTA
FACILITY NUMBER: 374604421
VISIT DATE: 03/01/2023
NARRATIVE
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LPA's observation showed adequate supply of hygiene products. LPA's observation of perishable food supply was adequate. The grocery receipts indicated enough perishable food was bought based on census for the month the complaint was reported.

Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation(s) occurred, therefore all allegations are therefore UNSUBSTANTIATED.

An exit interview was conducted with the Caregiver. A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided to the Licensee and her signature on this report confirms receipt of the Licensee Rights.
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Renita Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2