075601237-9-20-2022-15-AS-YFLS-CJMT84-20220926142940

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075601237
Report Date: 07/05/2022
Date Signed: 09/20/2022 11:16:13 AM

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
10/07/2020 and conducted by Evaluator Lisha Holmes

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20201007102423

FACILITY NAME:	SEIKO'S PLACE #2		FACILITY NUMBER:	075601237
ADMINISTRATOR:	LINSZKY, SEIKO		FACILITY TYPE:	740
ADDRESS:	5199 OLIVE DRIVE		TELEPHONE:	(925) 681-3229
CITY:	CONCORD	STATE: CA	ZIP CODE:	94521
CAPACITY:	0	CENSUS: 6	DATE:	07/05/2022
		UNANNOUNCED	TIME BEGAN:	02:05 PM
MET WITH:	Care Staff, Elmer "Eric" Ferrer		TIME COMPLETED:	04:20 PM

ALLEGATION(S):

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Facility staff did not seek medical attention in a timely manner
Facility failed to administer resident medication

INVESTIGATION FINDINGS:

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Amended Report:
On 09/20/22 at 10:05 AM, Licensing Program Analyst (LPA) L. Holmes conducted an unannounced subsequent visit and met with Care Staff to amend the complaint from Confidential to Public for the above allegations. LPA explained the purpose of the visit, Administrator Shahid Siddiqui was telephoned and approved Care Staff to sign the report.

Allegation: Facility staff did not seek medical attention in a timely manner.
Investigation Finding: SUBSTANTIATED
Based on interviews and record reviews, the facility did not provide a complete Physician’s Report for R1. The updated Appraisal/Needs and Services Plan for R1 has conflicting dates that include 2019, 03/02/2020, 04/27/20, and 09/01/2020 on one form. RP provided photos of R1’s overgrown toenails, a list of medications prescribed and dosage, and a copy of the Medication Administration Record (MAR) dated SEPT 2020 that conflicts with the facility’s MAR dated SEPT 2020.
Continued on next page, LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha Holmes	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022

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 15-AS-20201007102423

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: SEIKO'S PLACE #2	FACILITY NUMBER: 075601237
	VISIT DATE: 07/05/2022

NARRATIVE

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...Amended Report continued from LIC9099

The preponderance of evidence has been met. therefore this allegation is substantiated.

Allegation: Facility failed to administer resident medication.
Investigation Finding: SUBSTANTIATED
The Medication Administration Record (MAR) dated SEPT 2020 “comments/legend” does not properly document the administration of R1’s medication. A Preplacement Appraisal was completed on 04/27/2019. On 04/29/2019 Kaiser Permanente listed the medications prescribed for R1. On 10/29/2019 Kaiser Permanente increased the dosage of Losartan from 25mg to 50mg. The change in dosage was not documented on the MAR, and the eye medication is not documented as being administered. The updated Appraisal/Needs and Services Plan has conflicting dates that include 2019, 03/02/2020, 04/27/20, and 09/01/2020 all on one form. Based on interviews, record reviews and observations, the care staff failed to seek timely medical attention and administer medication. The preponderance of evidence has been met. Therefore, these allegation are substantiated.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D.

Failure to submit proof of correction (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. Appeal Rights and a copy of this report provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha Holmes	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20201007102423

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: SEIKO'S PLACE #2	FACILITY NUMBER: 075601237
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/05/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/29/2022 Section Cited CCR 87463(c)	1 2 3 4 5 6 7	87463 Reappraisals (c) The licensee shall arrange a meeting with the resident...health agency...when there is significant change in the resident’s condition, or once every 12 months... whichever occurs first... as specified in Section 87467... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	By POC due date, Adminstrator agreed to submit to CCLD a self certification that staff has read, understood and will comply with Title 22 Section 87463 to ensure residents have accurate physician's and appraisal reports at all times.
	8 9 10 11 12 13 14	Based on interview and record reviews, the inaccuracy of R1's reappraisal from a current physician's report posed a potential health & safety risk to resident in care.	8 9 10 11 12 13 14
Type B 07/29/2022 Section Cited CCR 87465(a)(1)	1 2 3 4 5 6 7	A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1)The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents	1 2 3 4 5 6 7	By POC due date, Adminstrator agreed to submit to CCLD a self certification that staff has read, understood and will comply with Title 22 Section 87465 in timely administering resident's medications and care needs.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by staff failing to adminiister resident's medication on time which posed a potential health & safety risk to residents in care:	8 9 10 11 12 13 14

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: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha Holmes	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022

LIC9099 (FAS) - (06/04)

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