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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604425
Report Date: 11/30/2022
Date Signed: 11/30/2022 11:28:28 AM

Unfounded


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
05/23/2022 and conducted by Evaluator Sabel Martinez
COMPLAINT CONTROL NUMBER: 08-AS-20220523145224
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:
11/30/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:House Manager, Tiffany LynchTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Resident's medical documentation is not maintained properly.
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 a resident's medical documentation was not maintained properly. An external source reported a resident’s Long-Term Care insurance documentation was not filled out properly resulting in late insurance compensation. Interviews with this sources, additional outside sources, and internal sources confirmed, that while some of the documentation may have been submitted past the due date, insurance benefits were still received by the residents.
(See attached LIC 812)
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2022
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 2
Control Number 08-AS-20220523145224
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: 11/30/2022
NARRATIVE
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Interviews and a review of California Code of Regulations, Title 22, and Health and Safety Code, corroborated there was not an existing regulation requiring the Licensee to submit Long Term Care Insurance documentation. Based on the evidence obtained during the complaint investigation, the allegation above is found to be UNFOUNDED, meaning that the allegations is false, could not have happened, or is without a reasonable basis.

No deficiencies were cited on today’s date. An exit interview was conducted with House Manager, Tiffany Lynch. A copy of this report and Licensee's Rights (LIC 9058) were provided to Administrator, Jennifer Fernandez, via electronic mail. An electronic mail read receipt confirms these documents were received by the administrator.

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

DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2