Incident investigation·July 12, 2023

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Administrator Bessie Pascual. Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 05/30/2023). According to the LIC624, the facility had a cabinet where the personal monies of residents were kept. On the morning of 05/25/2023, Resident #1 (R1) went into this cabinet and took all the money for themselves. [See LIC811 Confidential Names List for a description of person identifiers used in this report.] Facility staff later recovered in full, all the money which R1 took. During today’s visit, LPA, accompanied by the administrator, performed a facility tour, audited cash resource records, reviewed resident records, and interviewed pertinent staff. In addition to R1, the other residents in care were Resident #2 (R2), Resident #3 (R3), Resident #4 (R4), and Resident #5 (R5). According to staff interview: During the incident, Staff #1 (S1) briefly stepped away from the cabinet where the resident monies were kept, to assist another resident in the bathroom. S1 left the cabinet unlocked, which allowed R1 to take the monies. Upon discovering that the monies had been taken, S1 alerted the administrator, who called staff at R1’s day program (where R1 had since traveled to). Staff at the day program secured R1’s permission to search their bag and located the monies in question (returning them to facility staff intact). A preponderance of evidence exists to show that during the above incident, licensee’s staff did not take appropriate measures to safeguard residents’ cash resources, as was required. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] The facility is currently licensed to care for up to six (6) residents in total, of which four (4) may be non-ambulatory, and none may be bedridden. Per R3’s latest LIC602 Physician’s Report (dated 06/28/2023), R3 had recently become bedridden. (Per their prior LIC602 dated 09/29/2022, they were formerly non-ambulatory). Based on the latest facility license and latest fire clearance, Licensee was not authorized to care for bedridden residents. Prior to today’s visit, Licensee did not notify CCLD or their local fire authority that R3 had become bedridden, nor did Licensee start the process of applying for bedridden capacity. During records review, LPA observed: a) While Licensee maintained an active Surety Bond, the amount of the bond did not meet the minimum described in regulation, based on the actual amount of resident monies being safeguarded; b) Licensee did not possess a completed initial personal property inventory for R2, R3, and R4, as was required; and c) Licensee did not possess a completed Admissions Agreement for R3, as was required. Deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC809-D pages). CCLD determined one of these violations resulted in the facility not complying with its approved Fire Clearance from the local fire authority. An immediate Civil Penalty of $500.00 is thus charged and is noted on the LIC421-IM. LPA also issued one (1) Technical Violation (TV) to Licensee regarding ledger accounting of cash resources. An exit interview was conducted with Pascual, to whom a copy of this report, the LIC809-D pages, the LIC9102-TV, the LIC421-IM, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.