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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604425
Report Date: 11/22/2022
Date Signed: 11/22/2022 10:41:04 AM

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
10/03/2022 and conducted by Evaluator Sabel Martinez
COMPLAINT CONTROL NUMBER: 08-AS-20221003153544
FACILITY NAME:LA JOLLA CASA FIESTAFACILITY NUMBER:
374604425
ADMINISTRATOR:FERNANDEZ, JENNIFERFACILITY TYPE:
740
ADDRESS:5426 AVENIDA FIESTATELEPHONE:
(858) 775-6935
CITY:LA JOLLASTATE: CAZIP CODE:
92037
CAPACITY:6CENSUS: 6DATE:
11/22/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:House Manager, Tiffany LynchTIME COMPLETED:
10:50 AM
ALLEGATION(S):
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Licensee did not provide the resident an admission agreement
Licensee did not provide written notice of rate increase
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sabel Martinez, conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegations. The LPA was greeted by House Manager, Tiffany Lynch, identified himself, and disclosed the purpose of the visit.

The Department’s investigation consisted of review of records, and interviews with internal and external sources.

It was alleged the licensee did not provide the residents an admission agreement. Interviews with external sources revealed the facility ownership changed, and at that time, multiple residents did not receive an admission agreement from the new licensee. An interview with an internal source confirmed the resident’s documents obtained at the facility were the most updated records. Review of these records corroborated multiple admission agreements were not from the current facility, but instead the admission agreements from the previous Licensee.
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022
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-20221003153544
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: LA JOLLA CASA FIESTA
FACILITY NUMBER: 374604425
VISIT DATE: 11/22/2022
NARRATIVE
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It was alleged the licensee did not provide written notice of rate increase. Interviews with external sources reported the licensee did not provide proper written notice of rate increase. Interviews with additional external sources revealed the licensee did not provided proper written notices. Documents received by internal and external sources corroborated the licensee did not submit proper rate increase notices. Based on the evidence obtained during the complaint investigation, the preponderance of evidence standard was met. Therefore, the allegations of licensee did not provide the residents an admission agreement and licensee did not provide written notice of rate increase, were Substantiated and cited in the LIC 9099D. A Plan Of Correction was jointly formulated with the House Manager, Tiffany Lynch.

An exit interview was conducted with House Manager, Tiffany Lynch, to whom a copy this report, LIC 9099D, and Licensee's Rights (LIC 9058) were provided to.

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20221003153544
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: LA JOLLA CASA FIESTA
FACILITY NUMBER: 374604425
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/21/2022
Section Cited
CCR
87507(a)
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87507 Admission Agreement (a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any. This requirement is not met as evidence by:
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House Manager agreed to complete admission agreements for residents that did not receive an agreement from the new licensee. Proof will be submitted to the LPA by 12/15/2022.
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Based on interviews, and records review, the licensee did not complete individual written admission agreements which posed a potential health, safety, and personal rights risk to 2 of 6 persons in care.
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Type B
11/21/2022
Section Cited
HSC
1569.655
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1569.655 (a) If a licensee of a residential care facility for the elderly increases the rates of fees for residents or makes increases in any of its rate structures for services, the licensee shall provide no less than 60 days' prior written notice to the residents or the residents' representatives setting forth the amount of the increase, the reason for the increase, and a general description of the additional costs, except for an increase in the rate due to a change in the level of care of the resident. This subdivision shall not apply to optional services that are provided by individuals, professionals, or organizations under a separate fee-for-service arrangement with residents. This requirement is not met as evidenced by:
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Licensee submitted proof of written rate increase documentation to the LPA. POC was cleared on today's date.
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Based on interviews and record review, the Licensee did not provide written notice with a general description of the additional costs, which posed a potential health, safety, and personal rights risk to 2 of 6 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: Sabel Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3