374604478-4-25-2024-08-AS-LTEZ-D4TT49-20240430142331

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604478
Report Date: 04/25/2024
Date Signed: 04/25/2024 01:33:50 PM

Unsubstantiated

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
07/22/2022 and conducted by Evaluator Dang Nguyen

COMPLAINT CONTROL NUMBER: 08-AS-20220722110605

FACILITY NAME:	SOUTH PACIFIC VILLA		FACILITY NUMBER:	374604478
ADMINISTRATOR:	PRONOVOST, SHANEL		FACILITY TYPE:	740
ADDRESS:	543 GUIDERO WAY		TELEPHONE:	(916) 768-6948
CITY:	ENCINITAS	STATE: CA	ZIP CODE:	92024
CAPACITY:	6	CENSUS: 6	DATE:	04/25/2024
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Caregiver Alfred Riosa		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Licensee pursued resident eviction for invalid reason.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced subsequent visit to deliver a finding regarding the above prior complaint allegation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Alfred Riosa.

The Complainant alleged that Licensee served an eviction letter regarding Resident #1 (R1), and that the reason for the eviction was invalid. CCLD’s investigation involved an unannounced facility tour / welfare check, review of relevant facility and third-party records, and interviews of pertinent facility staff and outside sources.

Interview of facility manager and outside sources, and records reviewed, aligned to show: Licensee met with R1’s responsible person (RP) on 07/19/2022 for a care conference meeting, during which Licensee personally served RP with an eviction letter titled, “30 Days Notice.” [CONTINUED ON LIC 9099-C]

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024

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-20220722110605

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: SOUTH PACIFIC VILLA	FACILITY NUMBER: 374604478
	VISIT DATE: 04/25/2024

NARRATIVE

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[CONTINUED FROM LIC 9099] CCLD reviewed a copy of this letter, which cited the reason for eviction was that R1 now required a “higher level of care” beyond what the facility could provide. According to the 07/19/2022 care conference meeting agenda, and corroborated by interviews of both parties, one of the cited changes in condition for R1 since move-in was that they had increased “stiffness” in their body and that they had lost the ability to help staff during transfers and repositioning in, and to/from, bed. R1 had also become increasingly frightened during said transfers.

According to R1’s LIC602A Physician’s Report (dated 07/30/2021), their doctor determined that R1’s was of “non-ambulatory” status, as of that date. (According to the LIC602A’s printed instructions for the doctor, which conform to regulatory definitions, residents who cannot turn or reposition themselves in bed must be deemed “Bedridden” instead of “Non-Ambulatory.”) The LIC603 Pre-Placement Appraisal, which Licensee authored on 08/04/2021, corroborated that R1 was “Non-Ambulatory” status, as of that date.

Interviews of facility caregivers aligned to show: When R1 first moved-in to the facility, R1 was wheelchair-dependent and on hospice are, but their body was still strong enough that they could bear some of their own body weight during transfers. R1 at time of move-in required assistance of one caregiver for transfers, without needing a mechanical lift. They were also able to turn and reposition themselves in bed. Over time, R1 graduated to requiring a Hoyer-lift machine with a sling, plus assistance of two caregivers, for transfers. By the time of the 07/01/2022 care conference, R1 was no longer able to turn and reposition themselves in bed. Hospice agency electronic date and time-stamped progress notes showed: During the three months leading up to 07/19/2022, multiple hospice staff documented that R1 was becoming harder to transfer due to increasing stiffness in their body. Per R1’s hospice care plan, the Hoyer lift machine was added to the plan on an as-needed basis starting 01/12/2022.

The Department determined that the basis for R1’s eviction was valid. [CCLD found that the contents of Licensee’s eviction letter did not meet all regulatory requirements – these deficiencies were addressed on a separate Case Management visit report.] Based on interviews and records, a preponderance of evidence does not exist to prove that Licensee pursued a resident eviction for an invalid reason. The allegation is therefore Unsubstantiated.

An exit interview was conducted with Riosa, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024

LIC9099 (FAS) - (06/04)

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