Complaint Investigation Report

374604579-9-17-2025-08-AS-SJAB-DMJTHL-20251017144451

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

SAN DIEGO RO , 7575 METROPOLITAN DR. #109

This is an official report of an unannounced visit/investigation of a complaint received in our office on

06/02/2025 and conducted by Evaluator Tiffany Holmes

COMPLAINT CONTROL NUMBER: 08-AS-20250602082428

Staff are double/triple diapering resident

Licensing Program Analyst (LPA)Tiffany Holmes contacted the facility to deliver findings for a complaint investigation via tele-virtual. LPA identified herself to, and explained the purpose of the visit and the basic elements of the complaint with Sally Saif, Administrator

LPA previously conducted interviews with residents, staff, and outside sources, made observations, and obtained and reviewed pertinent records. LPA conducted the initial visit on June 11, 2025 and conducted a tour of the facility.

It was alleged that staff are double/triple diapering resident and that staff left resident in soiled diapers. Interviews revealed that the clients are being double diapered because the staff didn't want them to get their beds wet. Interviews with staff revealed they admitted to double dipaering the clients. Interviews with clients revealed they have been doubled diapered as well. Interviews with outside sources revealed Client 1 (C1) has been observed at program to be soiled wet and doubled diapered. Interviews revealed that a few of the clients are non verbal and they cannot voice if they are soiled or not. Interviews with the administrator revealed that the clients should not have been double diapered or left in soiled diapers. Interviews revealed there are plenty of diapers for the clients to be changed. Interviews revealed they have an order of incontince supplies that come to the facility monthly such as adult diapers, wipes and disposable sheets.

The Department has investigated the above-mentioned allegations and based on interviews, LPA observations, and records review, it was determined that the complaint allegations are substantiated. The preponderance of evidence proved that the alleged violation occurred.

An exit interview was conducted with Adminsitrator Sally Saif via face time and a copy of this report along with Licensee/Appeal Rights (LIC 9058 03/22) was provided via email. An electronic email read receipt confirms the documents were received.