374604454-9-16-2025-08-AS-LTEZ-DLW3AJ-20250926180450

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604454
Report Date: 01/08/2025
Date Signed: 09/16/2025 04:04:58 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
08/09/2024 and conducted by Evaluator Ryan Fulton

COMPLAINT CONTROL NUMBER: 08-AS-20240809113551

FACILITY NAME:	HUNTINGTON MANOR		FACILITY NUMBER:	374604454
ADMINISTRATOR:	DERAFERA, TESS		FACILITY TYPE:	740
ADDRESS:	14755 BUDWIN LN		TELEPHONE:	(858) 748-3381
CITY:	POWAY	STATE: CA	ZIP CODE:	92064
CAPACITY:	21	CENSUS: 19	DATE:	01/08/2025
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Med Tech Gerald Madla		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Resident had an unwitnessed fall resulting in the resident being on the floor for an extended period of time
Staff are not following the feeding/drinking care plan
Staff are not ensuring the residents diapers are changed timely

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ryan Fulton conducted an unannounced subsequent visit to deliver findings regarding the above allegation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Med Tech Gerald Mad.

The Department's investigation consisted of LPA observations, interviews with facility staff, residents, and outside sources, as well as records reviews.

It was alleged that the resident had an unwitnessed fall, resulting in the resident being on the floor for an extended period of time. It was reported that resident fell out of their bed and was left on the floor by staff members. Resident 5 (R5) is bedridden and needs to be rotated every two hours. However, after a review of R5's progress notes from the day the incident occurred at 10:05 am, staff did a round of checks and rotated R5 and did not note that the resident had a fall.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: David Roman
LICENSING EVALUATOR SIGNATURE:	DATE: 01/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2025

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-20240809113551

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: HUNTINGTON MANOR	FACILITY NUMBER: 374604454
	VISIT DATE: 01/08/2025

NARRATIVE

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At 11:15 am, the facility received a telephone call from the RP indicating that R5 was on the floor in their bedroom. At 11:15 am, staff entered R5's room and checked vitals and oxygen saturation. Staff interviews revealed that R5 was not on the floor when they did resident checks at 10:05 am. Staff also noted that the resident could not have been on the floor for long because a staff member walked by R5's room at 10:45 am and witnessed R5 still in bed. Since staff did regular checks on the resident that did not exceed 2 hours, this allegation is unsubstantiated.

It was alleged that staff are not following the feeding /drinking care plan. It was reported that staff were feeding R5 incorrectly, causing them to throw up and choke. After reviewing R5's needs and service plan, as well as the physician's report, it was revealed that R5 is on a modified diet that involves pureed food to be administered when they are being fed. Progress notes for R5 revealed that facility staff were aware of R5's need for pureed food and were documenting what types of food and when R5 was being fed these meals. Progress notes also revealed that staff followed the one-on-one feeding instructions specified in the physician's report and the needs and service plan. Staff interviews revealed that staff had adequate training and knowledge on how to feed a resident who is on a puree diet. Staff explained at length the process and procedure for feeding a person on a puree diet. Resident interviews revealed that they had had no issues with receiving the correct modified diet plans from the staff at the facility. Based on interviews and records reviews, this allegation is unsubstantiated.

Lastly, it was alleged that staff are not ensuring the residents' diapers are changed in a timely manner. It was specifically reported that R5 was being left in diapers that were soaked through on multiple occasions. After reviewing R5's physician's report, it was revealed that R5 required full assistance with incontinence and hygiene. LPA conducted a tour of the facility and did not observe any residents who needed to be changed and could not receive assistance. LPA also observed a resident using their call pendant for assistance with being changed, and staff assisted them in a timely manner. A records review of the progress notes for R5 revealed that from 7/01/2024 through 07/30/2024, staff did two-hour checks on R5 to ensure they were rotated and if needed, changed their diaper. Interviews with staff revealed that they were checking on R5 in the appropriate two-hour window. Based on LPA observations, records reviews and interviews, this allegation is unsubstantiated.

SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Ryan Fulton
LICENSING EVALUATOR SIGNATURE:	DATE: 01/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2025

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20240809113551

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: HUNTINGTON MANOR	FACILITY NUMBER: 374604454
	VISIT DATE: 01/08/2025

NARRATIVE

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This agency has investigated the complaint allegations, Resident had an unwitnessed fall resulting in the resident being on the floor for an extended period of time. Staff are not following the feeding/drinking care plan. Staff are not ensuring the residents diapers are changed timely. The Department has found that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations occurred. Therefore, the above allegations are found to be UNSUBSTANTIATED. An exit interview was conducted, and the report along with licensee appeal rights (LIC 9058 03/22) reviewed with Med Tech Gerald Madla

SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Ryan Fulton
LICENSING EVALUATOR SIGNATURE:	DATE: 01/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2025

LIC9099 (FAS) - (06/04)

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