374604452-11-7-2023-08-AS-SJAB-CY3PWB-20231130104027

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604452
Report Date: 11/07/2023
Date Signed: 11/07/2023 02:05:48 PM

Unsubstantiated

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
11/01/2023 and conducted by Evaluator Iby Strong

PUBLIC

COMPLAINT CONTROL NUMBER: 08-AS-20231101140854

FACILITY NAME:	MISSION CAREHOME SOUTH		FACILITY NUMBER:	374604452
ADMINISTRATOR:	LIMPIN, ROSEMARIE		FACILITY TYPE:	740
ADDRESS:	2534 NYE ST		TELEPHONE:	(619) 777-9674
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92111
CAPACITY:	6	CENSUS: 4	DATE:	11/07/2023
		UNANNOUNCED	TIME BEGAN:	01:25 PM
MET WITH:	Caregiver Linda Alforque		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Licensee did not administer medication as prescribed.
Licensee took residents personal property

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to deliver findings in the above complaint allegations. LPA identified herself and discussed the purpose of the visit with Caregiver Linda Alforque.

On October 23, 2023, Community Care Licensing (CCL) received a complaint alleging licensee did not issue medication as prescribed to Resident 1 (R1) and licensee took R1's personal item without permission. During the investigation, LPA Strong collected pertinent resident records as well as facility documentation and conducted interviews.

Based on Resident 1 (R1) Physician’s Report dated May 26, 2023, R1 is diagnosed with a chronic pain, can communicate need, is able to leave facility unassisted and can administer own medication. Additional records revealed R1 was receiving Hospice Care services by an outside agency.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20231101140854

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: MISSION CAREHOME SOUTH	FACILITY NUMBER: 374604452
	VISIT DATE: 11/07/2023

NARRATIVE

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Continued from LIC9099

According to allegation, R1 was denied pain medication on October 15, 2023, by care staff. Based on interview with R1, R1 states they were not prescribed any pain medication and facility staff refused to provide R1 with such medication. Interview with staff revealed S1 and S2 offered R1 pain medication throughout the day of October 15, 2023, but R1 denied the medication. Interview with an outside source confirmed that R1 was prescribed pain medication, and this was communicated with R1.

It was also alleged that R1’s cellular phone was taken without permission and made inaccessible to R1 by staff. Interviews with R1 revealed that staff would not allow residents to contact emergency personnel to assist with pain management on October 15, 2023. Interview with staff revealed that R1 contacted emergency personnel, they arrived and left without taking R1. It was also revealed that staff did not take R1’s cell phone away, and the cell phone was later found and given to R1’s responsible party. Interview with outside source did not reveal any information to corroborate that licensee took R1’s cell phone.

Based on LPA's interviews, and record reviews there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegation is unsubstantiated. An exit interview was conducted with Caregiver Linda Alforque, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

LIC9099 (FAS) - (06/04)

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