015600255-4-25-2023-15-AS-KHOS-CRFQAJ-20230502120001

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015600255
Report Date: 04/25/2023
Date Signed: 04/25/2023 03:02:04 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/30/2022 and conducted by Evaluator Gregory Clark

COMPLAINT CONTROL NUMBER: 15-AS-20220630135819

FACILITY NAME:	MERCY RETIREMENT & CARE CENTER		FACILITY NUMBER:	015600255
ADMINISTRATOR:	ALAN S FOX		FACILITY TYPE:	741
ADDRESS:	3431 FOOTHILL BOULEVARD		TELEPHONE:	(510) 534-8540
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94601
CAPACITY:	160	CENSUS: 74	DATE:	04/25/2023
		UNANNOUNCED	TIME BEGAN:	01:25 PM
MET WITH:	Elvira Suciu, Resident Care Director		TIME COMPLETED:	03:10 PM

ALLEGATION(S):

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Staff did not dispense medication assistance to clients in care
Facility did not report medication errors
Facility did not conduct a reappraisal of residents care needs

INVESTIGATION FINDINGS:

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On 4/25/23 p.m. Licensing Program Analyst (LPA) Greg Clark conducted an unannounced visit to deliver findings for the above allegations. LPA met with Elvira Suciu, Resident Care Director and explained the purpose of the visit.

During the course of investigation, LPA interviewed the reporting party (RP) and facility staff (S1), reviewed records including med tech schedules for April, May and June 2022, Medication administration records (MARs) for April, May and June 2022, written warning records for med techs, staff training sign-in sheets from April, May and June 2022, physician communication forms and R1's records including physician's report.

**report continuews on LIC9099C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory Clark	TELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023

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 15-AS-20220630135819

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MERCY RETIREMENT & CARE CENTER	FACILITY NUMBER: 015600255
	VISIT DATE: 04/25/2023

NARRATIVE

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***report continuesfrom LIC9099**

Staff did not dispense medication assistance to clients in care

LPA reviewed MARs from April, May and June 2022. LPA observed that all medications we signed off as dispensed by the med techs. Facility uses an electronic MAR system.

Facility did not report medication errors

LPA reviewed written warning records dated 4/27/22 for med techs documented medication administration errors. LPA also reviewed physician communication form dated 5/02/22 that documents that the medication errors would not cause harm to the resident in care. Facility staff did not report the medication error to CCL as the error did not threaten the welfare, safety or health of the resident. Facility staff were re-trained on proper medication administration procedures on 4/29/22.

Facility did not conduct a reappraisal of resident’s care needs

LPA reviewed the facility file for R1. R1 lives in the assisted living section of the building. R1’s family provides R1 with a 1:1 aide. R1 is currently on hospice. LPA observed that physician’s reports for R1 were completed on 4/19/19, 5/20/21 and 9/10/23. R1’s primary diagnosis is documented as Parkinsons. R1 is not diagnosed with dementia.

This agency has investigated the allegations that staff did not dispense medication assistance to clients in care, facility did not report medication errors and facility did not conduct a reappraisal of resident’s care needs. Based on LPA's observations, record review and interviews which were conducted the allegations were found to be unsubstantiated. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted, a copy of this report provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory Clark	TELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023

LIC9099 (FAS) - (06/04)

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