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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200723
Report Date: 03/27/2023
Date Signed: 03/27/2023 04:34:47 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
11/10/2022 and conducted by Evaluator Lizette Francisco
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20221110120910
FACILITY NAME:KIMBILIOFACILITY NUMBER:
019200723
ADMINISTRATOR:ALANNA SPENCERFACILITY TYPE:
772
ADDRESS:1480 159TH STREETTELEPHONE:
(510) 200-9134
CITY:SAN LEANDROSTATE: CAZIP CODE:
94578
CAPACITY:14CENSUS: 8DATE:
03/27/2023
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Jonathan Haskins, Clinical Case ManagerTIME COMPLETED:
04:50 PM
ALLEGATION(S):
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Facility staff mismanaged resident’s medication
INVESTIGATION FINDINGS:
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On 3/27/2023 starting at 2:15 PM, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to deliver findings for the above allegation. Upon arrival, LPA was greeted by Care Staff, Elesha McCalister and explained the purpose of the visit. Administrator, Alanna Spencer later arrived at 3:55 PM.

During the course of the investigation, LPA reviewed records, interviewed staff and client, and obtained the following documents: Centrally Stored Medication and Destruction Record (CSMDR), Medication Administration Record (MAR), Residential Referral Form, Preplacement, Identification and Emergency Information (ID), Physician's Report, and Preplacement Appraisal. It was alleged facility staff mismanaged resident's medication. Based on information obtained by complainant, facility staff is not administering client's medications due to medications missing and not being refilled.

REPORT CONTINUES ON LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Lizette Francisco
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023
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 2
Control Number 15-AS-20221110120910
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: KIMBILIO
FACILITY NUMBER: 019200723
VISIT DATE: 03/27/2023
NARRATIVE
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LPA reviewed C1's Medication Administration Record (MAR) and observed there were multiple days where the following medications for October of 2022 and November of 2022 were not initialed: escitalopram, quentapine, gabaperin and lithium carbonate. However, 2 of 4 staff stated that the medications were administered, but staff did not initial the MAR. 2 of 4 staff stated if medications are missed, staff will initial and document the reason for the missed medication. 3 of 4 staff stated if there was any medications that are mismanaged, then staff will notify Administrator.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conduct and a copy of report provided to Administrator.




SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Lizette Francisco
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2