374604478-9-25-2024-08-AS-SJAB-DFXU6U-20250421151856

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604478
Report Date: 09/25/2024
Date Signed: 09/25/2024 04:57:37 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
08/18/2023 and conducted by Evaluator Tiffany Holmes

COMPLAINT CONTROL NUMBER: 08-AS-20230818110847

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:	09/25/2024
		UNANNOUNCED	TIME BEGAN:	11:40 AM
MET WITH:	Angelina Escobar, Staff		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff pushed resident.
Staff yelled at resident.
Staff administered medication to resident that was not prescribed.
Staff forced resident to stand up.
Staff did not follow food service requirements
Staff broke resident’s hearing aid.
Staff slept while on duty.
Staff are unable to communicate with residents due to language barrier.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced subsequent visit to deliver findings regarding the above complaint allegations. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Angelina Escobar, Staff.

LPA conducted the initial investigation visit on August 24, 2023, and was able to interview clients, facility staff, and outside sources. LPA also reviewed records and conducted a physical inspection of the facility. It was alleged that staff pushed resident. Interviews revealed the staff are gentle with the residents. Interviews revealed that the staff assist the residents with showering and toileting. Interviews with staff revealed they are not rough with the residents and they have not pushed any of the residents. Staff denied the allegation.

[CONTINUED ON LIC 9099-C]

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024

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-20230818110847

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: SOUTH PACIFIC VILLA	FACILITY NUMBER: 374604478
	VISIT DATE: 09/25/2024

NARRATIVE

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[CONTINUED FROM LIC 9099] It was alleged that staff yelled at resident. Interviews revealed they talk nicely to the residents and don't yell at them. Interviews revealed that sometimes staff speak louder to the residents because they have a hard time hearing at a regular tone so they speak up. Interviews revealed that someone could possibly misconstrue them yelling instead of just talking loudly so they can hear. Staff denied the allegation of yelling at the residents.

It was alleged that staff administered medication to resident that was not prescribed. Interviews revealed staff denied the allegation of giving the resident medications that are not prescribed to them. Interviews revealed that they only give the medication prescribed to the residents. According to a record review, the residents medications were accounted for and the staff denied giving the residents other residents medications. Interviews revealed that if they were to give another resident someone else's medications they would be short and they have not been short on the medications.

It was alleged that staff forced resident to stand up. Interviews revealed the staff assist the residents with standing up they don't force them to get up. Interviews revealed they have the residents stand when trying to assist them with changing or toileting. Any time a resident refuses they do not force the residents to do any thing they do not want to do.

It was alleged that staff did not follow food service requirements. Interviews revealed the residents are fed good meals. Interviews revealed the staff cut up the food for the residents to eat and make sure the bites are small enough so they don't choke. Interviews revealed the staff give the residents choices when eating and what they will eat.

It was alleged that staff broke resident’s hearing aid. Interviews revealed staff denied breaking the resident's hearing aid. When they observed the hearing aid was broken they reported it to the licensee and to the family that was around the same day the spouse observed the case to have a crack in it as well.

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20230818110847

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: SOUTH PACIFIC VILLA	FACILITY NUMBER: 374604478
	VISIT DATE: 09/25/2024

NARRATIVE

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[CONTINUED FROM LIC 9099] It was alleged that staff slept while on duty. Interviews revealed the staff do not sleep while on duty, the staff denied this allegation. There are enough staff working at the facility and the staff will take a nap on the break times only. Interviews revealed that the licensee has explained to the staff not to sleep out in the open they can go into the staff room if they want to take a nap. Interviews revealed the staff are live in and if they are on their breaks they may take a quick nap but not in any of the open areas around the facility.

It was alleged that staff are unable to communicate with residents due to language barrier. Interviews revealed the staff speak english and can communicate with the residents. Interviews revealed the staff are all Bi lingual and speak Tagalog as well. Interviews revealed the staff do sometimes speak Tagalog while trying to help each other when assisting the residents. Interviews revealed the residents do not have an issue with that.

The Department determined that the allegations of staff pushed resident,
staff yelled at resident, staff administered medication to resident that was not prescribed,
staff forced resident to stand up, staff did not follow food service requirements, staff broke resident’s hearing aid, staff slept while on duty and staff are unable to communicate with residents due to language barrier are unsubstantiated.

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

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024

LIC9099 (FAS) - (06/04)

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