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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601483
Report Date: 12/22/2023
Date Signed: 12/22/2023 12:03:52 PM

Substantiated


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
12/20/2023 and conducted by Evaluator Laura Hall
COMPLAINT CONTROL NUMBER: 15-AS-20231220122433
FACILITY NAME:ST. LOURDES HOMEFACILITY NUMBER:
015601483
ADMINISTRATOR:BALINTONA, JUSTINOFACILITY TYPE:
740
ADDRESS:1626 ASHBURY LANETELEPHONE:
(510) 265-0818
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY:6CENSUS: 4DATE:
12/22/2023
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Corazon Mariano, CaregiverTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Staff dispensed medication that was not prescribed to resident.
INVESTIGATION FINDINGS:
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On 12/22/2023 at 10:20am, Licensing Program Analysts (LPAs), L. Hall and T. Syess-Gibson arrived unannounced to conduct the 10-day initial visit and deliver complaint findings for the allegation above. LPAs met with Corzaon Mariano, Caregiver and explained the reason for the visit. Administrator Justion Balintona, arrived at 10:55am.

During the investigation LPA interviewed Staff 1 (S1), obtained and reviewed the following documents for R1: admission agreement and physician's report. During interview with S1 he admitted that he offered the melatonin to R1, there was not a prescription, and R1 took the medication. During record review LPAs observed the facility did not have a medical administrative record (MAR) for R1. R1 no longer resides at facility.

Continued on 9099C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2023
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 3
Control Number 15-AS-20231220122433
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: ST. LOURDES HOME
FACILITY NUMBER: 015601483
VISIT DATE: 12/22/2023
NARRATIVE
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Continued from LIC9099.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of the appeal rights and this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20231220122433
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: ST. LOURDES HOME
FACILITY NUMBER: 015601483
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/23/2023
Section Cited
CCR
87465(e)
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87465 Incidental Medical and Dental Care (e) For every prescription and nonprescription PRN medication... there shall be a signed, dated written order from a physician... maintained in the residents file, and a label on the medication. This requirement was not met as evidence by:
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Administrator agreed to review regulation 87465 and submit self-certification that the regulation has been reviewed and will be abided by going forward to CCLD by POC date.
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Based on observation and record review the Licensee did not comply with the section cited above in administering over-the-counter medication to R1 which poses a potential health and safety risk for person 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.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3