Sapphire Escondido Estates

Allegation investigated: Lack of care and supervision resulting in resident being injured

Licensing Program Analysts (LPAs) Tricia Danielson and Kathleen Banrasavong arrived unannounced to the facility to initiate an investigation into the allegation listed above. LPAs met with Caregiver Imelda "Amy" Santos and explained the purpose of the visit. Administrator Liz Rivera was notified via telephone of LPA's visit and arrived a short time later. During today's visit, LPA's toured the facility and interviewed one (1) staff, one (1) resident, and reviewed documentation pertinent to Resident #1 (R1) and Resident #2 (R2). Regarding the allegation "Lack of care and supervision resulting in resident being injured", it was alleged that R1 was left unsupervised which allowed them to hit R2 with a hairbrush several times. Review of R1's Physician's report indicated R1 can be verbally aggressive, can display inappropriate behavior at times, and is not at risk for self-abuse. Review of R1's Resident Appraisal indicated R1 is easily upset with behavioral outbursts especially around unfamiliar people and group activities may provoke an outburst as well. R1's Individual Service Plan revealed R1 displays paranoia, delusional thinking, agitation and anger at times related to their diagnosis. Records reviewed did not indicate R1 required direct supervision at any given time. (CONTINUED ON LIC9099-C) Unsubstantiated (CONTINUED FROM LIC9099) Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted and a copy of this report was provided along with LIC811- Confidential Names list.the state’s words, verbatim · CDSS document, May 10, 2023 · control 18-AS-20230502105304

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Tricia Danielson Kathleen Banrasavong arrived unannounced to the facility to conduct a case management visit to address a deficiency observed during the investigation of complaint control number 18-AS-20230502105304. During review of facility records on 5/10/2023, it was discovered that Resident #1 (R1) has a sole primary diagnosis of paranoid schizophrenia. R1's ongoing behavior is not compatible with the other residents of the facility and has upset the resident group in it's entirety. On 4/28/2023, R1 unjustifiably physically assaulted Resident #2 (R2), who is bedridden and non-verbal, with a hairbrush. Therefore, based on LPA's observations, the following deficiencies were cited per Title 22, Division 6 of the California Code of Regulations. See LIC 809D. An exit interview was conducted and a copy of this report was provided along with LIC811- Confidential Names list and Appeal Rights.the state’s words, verbatim · CDSS document, May 10, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87455(c)(3)(A) · Plan of correction due date: May 31, 2023

Acceptance and Retention Limitations-(c) No resident shall be accepted or retained if any of the following apply:(3) The resident's primary need for care and supervision results from either: (A) An ongoing behavior, caused by a mental disorder, that would upset the general resident group. This requirement was not met as evidenced by: The licensee did not follow acceptance and retention limitations. Based on review of R1's physician's report, R1 is soley diagnosed with paranoid schizophrenia and upset the resident group when they unjustifably assaulted R2 with a hairbrush. This poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 10, 2023

Plan of correction: The licensee will work with R1's conservator to find alternative appropriate placement at another licensed facility. Proof of R1's placement elsewhere to be submitted to LPA by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kayla Hilario, conducted an unannounced Required 1 - Year Visit. The facility file was reviewed prior to the visit. LPA met with Administrator Ali Naghibi and we discussed the purpose of the visit. All staff present have a current criminal record clearance. LPA conducted a tour of the facility, both inside and outside and observed the residents in care. In accordance with the Department’s Infection Control, LPA provided technical assistance, evaluated, and observed the facility's implementation of their mitigation plan to include disinfection, testing surveillance, and screening protocols as well as the use of personal protective equipment. No deficiencies were cited or observed on this date. The Administrator will be provided a copy of their appeal rights (LIC9058 01/16). An exit interview was conducted with Administrator Ali Naghibi and a copy of this report will be emailed to the Administrator with an electronic read receipt as confirmation of documents.the state’s words, verbatim · CDSS document, Nov 29, 2021

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.