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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604702
Report Date: 08/15/2024
Date Signed: 08/15/2024 01:08:34 PM

Substantiated


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
11/27/2023 and conducted by Evaluator Tiffany Holmes
COMPLAINT CONTROL NUMBER: 08-AS-20231127171640
FACILITY NAME:LOVING HANDS SENIOR CAREFACILITY NUMBER:
374604702
ADMINISTRATOR:CONWRIGHT, JOSHUAFACILITY TYPE:
740
ADDRESS:3245 STAR ACRES DRTELEPHONE:
(619) 772-9873
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91978
CAPACITY:6CENSUS: 3DATE:
08/15/2024
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Stephanie Conwright, Staff TIME COMPLETED:
01:20 PM
ALLEGATION(S):
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Staff are not adequtely trained.

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA)Tiffany Holmes conducted an unannounced complaint visit to the facility to close out the complaint and the above-mentioned allegation. LPA gained access to the facility, identified herself, and met with Stephanie Conwright, Staff to discuss the purpose of the visit.

During the visit, LPA toured the facility, reviewed and obtained copies of facility records and conducted interviews. It was alleged that staff are not adequtely trained. Interviews revealed the staff worked for the prior administrator. Interviews revealed that the administrator trained the staff. LPA observed staff files and did not observe any documentation of any training the staff completed. Interviews revealed they did not have any proof of the trainings the other administrator provided. Interviews revealed the staff have been working at the facility since it opened under new management in October of 2023.

There was supporting witness statements and no documents to substantiate staff are not adequtely trained. A deficiency is cited per Title 22 California Code of Regulations.

An exit interview was conducted with Stephanie Conwright, Staff. A copy of this report and the Licensee's Rights (LIC9058 03/22) were provided at the conclusion of the visit.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
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
11/27/2023 and conducted by Evaluator Tiffany Holmes
COMPLAINT CONTROL NUMBER: 08-AS-20231127171640

FACILITY NAME:LOVING HANDS SENIOR CAREFACILITY NUMBER:
374604702
ADMINISTRATOR:CONWRIGHT, JOSHUAFACILITY TYPE:
740
ADDRESS:3245 STAR ACRES DRTELEPHONE:
(619) 772-9873
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91978
CAPACITY:6CENSUS: 3DATE:
08/15/2024
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Stephanie Conwright, Staff TIME COMPLETED:
01:20 PM
ALLEGATION(S):
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Staff did not seek resident timely medical attention.
Staff did not prevent resident from falling.
Staff did not ensure that resident was adequately hydrated.
Staff did not follow resident's care plan.
Staff did not effectively communicate with resident's responsible party.
Staff did not allow resident's responsible party access to resident's room to retrieve the resident's clothing.
Staff are not available to the residents at night.
Staff did not follow resident's admission agreement
Staff did not assist resident with making phone calls.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA)Tiffany Holmes conducted an unannounced complaint visit to the facility to close out the complaint and the above-mentioned allegations. LPA gained access to the facility, identified herself, and met with Stephanie Conwright, Staff to discuss the purpose of the visit.

During the visit, LPA toured the facility, reviewed and obtained copies of facility records and conducted interviews. It was alleged that staff did not seek resident timely medical attention. Interviews revealed on November 16, 2023 R1 went to the hospial after their Responsible Party (RP) came to visit them and R1 didnt respond. Interviews revealed that R1 had finished eating and was changed and was moved to the living room by another staff when the RP came in. Interviews revealed that staff started to rub R1s chest and called their name and R1 responded but did not open their eyes. The RP called 911 and interviews with staff revealed the change in condtion happened almost immediately after sitting down in the recliner. Interviews revealed R1 never returned to the facility after they went to th hospital.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 08-AS-20231127171640
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: LOVING HANDS SENIOR CARE
FACILITY NUMBER: 374604702
VISIT DATE: 08/15/2024
NARRATIVE
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It was alleged that staff did not prevent resident from falling. Interviews revealed R1 did have a fall. Interviews revealed that the staff work closely with the residents and sometimes they just fall. Interviews revealed that staff can be right next to the residents and they will still fall. All staff try to prevent residents from falling and hurting themselves. Interviews revealed that R1 fell on October 2, 2023 by tripping over their foot after exercising and sustained injuries to the side of their face. Interviews revealed staff called 911 and R1 sustained a cut above their right eyebrow. Interviews revealed they contacted R1s RP and advised them of the incident.

It was alleged that staff did not ensure that resident was adequately hydrated. Interviews revealed the staff kept the two clients hydrated by asking them did they want water and when they refused they offered for them to take a sip. Interviews revealed there was also something available for the residents to drink to stay hydrated at all times. Interviews revealed there were times one of the residents would refuse to drink but after a few prompts they would take a drink. Interviews revealed the staff conducted rounds hourly or as needed and the staff would ask if they would like something to drink each round. Interviews revealed all residents have a 16 oz cup of water in their rooms that is refilled as needed.

It was alleged that staff did not follow resident's care plan. Interviews revealed the care plan was followed and maintained by staff. Interviews revealed the staff shower R1 twice a week at minimum. Interviews revealed staff would change R1 clothes everyday as well. Interviews revealed that there was no set care plan in place for showers they just completed the task.

It was alleged that staff did not effectively communicate with resident's responsible party. Interviews revealed the staff communicated with the Responsible Party (RP) daily or as needed. Interviews revealed the RP would call and request things of the staff and they would comply. The staff know how to call 911 and the administrator in case of an emergency and can effectively communicate with emergency personnel if need be and the RP.



SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 08-AS-20231127171640
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: LOVING HANDS SENIOR CARE
FACILITY NUMBER: 374604702
VISIT DATE: 08/15/2024
NARRATIVE
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It was alleged that staff did not allow resident's responsible party access to resident's room to retrieve the resident's clothing. Interviews revealed that R1 shared a room with another resident. Interviews revealed one day the RP arrived at the facility while the other resident was taking a nap and they requested to go in and retrieve R1’s items. Interviews revealed staff explained to them the the other resident was asleep and that staff would retrieve the items for them. Interviews revealed anytime there was an issue the staff would contact the RP with the issue.

It was alleged that staff are not available to the residents at night. Interviews revealed the staff are awake staff and they continuously monitor the residents as they sleep, watch television or just lay in their beds. The staff will continue to do their rounds and check to make sure all of their needs are met.

It was alleged that staff did not follow resident's admission agreement. Interviews revealed that the staff followed R1s admission agreement. They did not provide transportation for the residents. The agreement was signed and it stated that they would provide the transportation. Interviews revealed R1 and the RP discussed transportation and stated that they would try to assist in transportation and once staff spoke with their insurance they decided they would not be providing transportation to residents. Interviews revealed that once the decision was made not to provide the transportation they contacted the RP and advised them of the situation. RP was not happy with the decision and voiced their concerns about the facility not providing the transportation as stated in the admission agreement.

It was alleged that staff did not assist resident with making phone calls. Interviews revealed that staff assisted R1 in making phone calls to their significant other. Interviews revealed there were times when R1 would want to talk and other times they did not. Staff revealed they cannot make the resident talk on the phone if they don't want too. Interviews revealed that there were a couple of times the significant other did not answer their phone, however staff would leave a message.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 08-AS-20231127171640
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: LOVING HANDS SENIOR CARE
FACILITY NUMBER: 374604702
VISIT DATE: 08/15/2024
NARRATIVE
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There were not any supporting witness statements to substantiate the allegations of the staff did not seek resident timely medical attention, staff did not prevent resident from falling, staff did not ensure that resident was adequately hydrated, staff did not follow resident's care plan, staff did not effectively communicate with resident's responsible party, staff did not allow resident's responsible party access to resident's room to retrieve the resident's clothing, staff are not available to the residents at night, staff did not follow resident's admission agreement and staff did not assist resident with making phone calls.

An exit interview was conducted with Stephanie Conwright, Staff. A copy of this report and the Licensee's 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: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 08-AS-20231127171640
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: LOVING HANDS SENIOR CARE
FACILITY NUMBER: 374604702
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/30/2024
Section Cited
CCR
87411(c)(6)
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The licensee shall maintain documentation pertaining to staff training in the personnel records, as specified in Section 87412(c)(2)... This regulation is not met as evidenced by:
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Administrator stated they will document the training for all staff and will provide the Department with proof of training by POC date. Administrator will also create a training log for each staff to ensure required training are documented and will provide the training logs to the Department by the POC date of 08/30/2024.
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Based on interview with Administrator, training was provided with previous owner, however, upon a review of S1, S2, S3, S4s, records, there was no documented staff training or training documented for new staff. This poses a potential safety risk to 2 of 2 (R1 & R2) residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6