374604490-1-21-2025-08-AS-SJAB-DG8P5S-20250430110113

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604490
Report Date: 01/21/2025
Date Signed: 01/21/2025 04:17:22 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
11/07/2022 and conducted by Evaluator Tiffany Holmes

COMPLAINT CONTROL NUMBER: 08-AS-20221107101801

FACILITY NAME:	COLLEGE TOWN SENIOR RETIREMENT VILLA INC		FACILITY NUMBER:	374604490
ADMINISTRATOR:	PETROSYAN, ANNA		FACILITY TYPE:	740
ADDRESS:	5252 STONE CT		TELEPHONE:	(619) 432-1236
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92115
CAPACITY:	6	CENSUS: 6	DATE:	01/21/2025
		UNANNOUNCED	TIME BEGAN:	04:00 PM
MET WITH:	Miguel Sanchez, Caregiver		TIME COMPLETED:	04:25 PM

ALLEGATION(S):

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Neglect to resident resulting in serious bodily injury.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced visit to deliver findings for a complaint investigation regarding the above-mentioned allegation. LPA identified herself and met with Miguel Sanchez, Caregiver, to discuss the purpose of the visit and elements of the complaint.

The Department's investigation included interviews and a review of pertinent records. It was alleged that Neglect/Lack of Supervision resulted in serious bodily injury. On 11/07/22 the San Diego Adult and Senior Care Program received a complaint via a SOC341. Interviews with an outside source revealed Resident 1 (R1), was taken to Sharp Memorial Hospital on 11/01/22, where R1 was found to have urosepsis, fractured ribs, and a facial fracture. A record review of hospital records document that R1 had abrasions to their nose and left knee, dried blood on their fingers, and wound to knees in various stages of healing. Interviews revealed on 11/03/2023 that Staff 1 (S1) at the facility did not know R1 sustained the injuries. Interviews revealed that R1 was found on the floor on 11/01/22 and was sent to the hospital. R1 was also sent to the Hospital ER on these other dates of 10/19/22, 10/20/22, and 10/21/22 for claims of nausea and vomiting with blood.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:	DATE: 01/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025

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-20221107101801

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: COLLEGE TOWN SENIOR RETIREMENT VILLA INC	FACILITY NUMBER: 374604490
	VISIT DATE: 01/21/2025

NARRATIVE

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Interviews with the licensee, staff, and staff at St. Paul’s Pace, including medical personnel, was conducted. It was determined College Town licensee and staff had contacted St. Paul’s Pace on several occasions prior to R1’s last hospitalization while at College Town to request he be transferred to another facility that could provide a higher level of care to R1. Interviews revealed that College Town had reported a change in behavior and declining health to St. Paul’s Pace due to R1 not being able to stand and being more prone to falls. Interviews with outside source revealed a social worker from St. Paul’s Pace confirmed this and provided documentation. Interviews revealed that although several injuries were documented there wasn’t any documentation of concern for neglect, abuse, or non-accidental injuries were noted.

The investigation did not produce substantiating evidence or supporting witness statements to substantiate the allegation of neglect or lack of supervision therefore the allegation is unsubstantiated.

An exit interview was conducted with Miguel Sanchez, Caregiver. A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided and their signature on this report confirms receipt of the Licensee Rights.

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:	DATE: 01/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025

LIC9099 (FAS) - (06/04)

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