045002440-6-21-2022-25-AS-APEZ-CFWLYT-20220701091053

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 045002440
Report Date: 06/21/2022
Date Signed: 06/21/2022 11:58:49 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/05/2021 and conducted by Evaluator Donna Gurriere

COMPLAINT CONTROL NUMBER: 25-AS-20211105105258

FACILITY NAME:	COUNTRY CREST ASSISTED LIVING		FACILITY NUMBER:	045002440
ADMINISTRATOR:	DAVIS, IRENE		FACILITY TYPE:	740
ADDRESS:	55 CONCORDIA LN		TELEPHONE:	(530) 533-7857
CITY:	OROVILLE	STATE: CA	ZIP CODE:	95966
CAPACITY:	150	CENSUS:	DATE:	06/21/2022
		UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	IRENE DAVIS		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Staff mismanaged a resident’s medication.

INVESTIGATION FINDINGS:

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Donna Gurriere, Licensing Program Analyst was in contact and met with Irene Davis, Administrator. It was alleged that Staff mismanaged a resident’s medication.

LPA Gurriere completed the required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID 19 infection to affirm no COVID-19 related symptoms. The administrator/staff person was contacted to complete a facility risk assessment. LPA Gurriere ensured that hand sanitizer was applied before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask. Additionally, LPA Gurriere was screened by a staff person upon entering the facility.

continued

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Donna Gurriere	TELEPHONE: (530) 895-5033
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022

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 25-AS-20211105105258

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: COUNTRY CREST ASSISTED LIVING	FACILITY NUMBER: 045002440
	VISIT DATE: 06/21/2022

NARRATIVE

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During the investigation process, the administrator, physician, resident and five staff persons were interviewed. In addition, documents were obtained to include Physician’s report, physician’s orders, medication log, admission agreement, texting communication and physician’s communication.

It was reported that a resident (Resident 1) provided the facility nurse with a medication change order from a neurologist. The medication change order did not come from the neurologist; however, came from the resident. The nurse was not comfortable with the order change due to the amount of medication increase. The nurse contacted the resident’s General Practitioner (GP) physician, as the nurse could not get a hold of the neurologist, because it was late in the day. The GP advised the nurse to not increase the resident’s medication until there was verification from the neurologist of the medication change.

During the investigation, the resident’s GP was contacted, and he confirmed that he told the nurse to hold the medication until the neurologist could confirm the medication change. During the time of the incident, the resident reported that he was physically not feeling well and the resident had the staff person contact emergency services to be taken to the hospital. Once the resident was at the hospital, he was able to see his neurologist and the neurologist made the appropriate medication change.

Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are Unsubstantiated

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Donna Gurriere	TELEPHONE: (530) 895-5033
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022

LIC9099 (FAS) - (06/04)

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