075601314-4-7-2023-15-AS-KHOS-CQYPR5-20230417113211

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075601314
Report Date: 04/07/2023
Date Signed: 04/07/2023 01:41:24 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
04/05/2023 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20230405092226

FACILITY NAME:	MOUNTAIN RIDGE SENIOR CARE		FACILITY NUMBER:	075601314
ADMINISTRATOR:	LABAO, EVELYN C.		FACILITY TYPE:	740
ADDRESS:	5187 DOMENGINE WAY		TELEPHONE:	(925) 776-7537
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94531
CAPACITY:	6	CENSUS: 4	DATE:	04/07/2023
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Evelyn Labao, Administrator		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff mismanaged residents' medications

INVESTIGATION FINDINGS:

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On 04/07/23 at 12:15PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit, met with administrator (ADM), conducted interviews and record reviews and delivered investigation finding to ADM. LPA explained the purpose of the visit with administrator.

Allegation: Staff mismanaged residents' medications
Investigation Finding: SUBSTANTIATED
During visit, ADM confirmed with LPA that she pre-poured residents (R1, R2, R3, R4) medications in different containers from their prescribed storage bottles/bubble packs because she will be away for a few days. On 03/30/23, witness (W1) also observed residents’ medications stored in different containers from their original prescription bottles/bubble packs. Continued on next page, LIC 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023

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-20230405092226

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: MOUNTAIN RIDGE SENIOR CARE	FACILITY NUMBER: 075601314
	VISIT DATE: 04/07/2023

NARRATIVE

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Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff mismanaged residents’ medication was found to be 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: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20230405092226

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: MOUNTAIN RIDGE SENIOR CARE	FACILITY NUMBER: 075601314
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/07/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/28/2023 Section Cited CCR 87465(h)(5)	1 2 3 4 5 6 7	The following requirements shall apply to medications which are centrally stored: Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.	1 2 3 4 5 6 7	By POC due date, Administrator agreed to complete and submit to CCLD in-service staff retraining certification on proper medication administration to ensure compliance with Title 22 Section 87465 (h) (5).
	8 9 10 11 12 13 14	This requirement was not met as evidenced by staff mismanaging residents' medications which posed a potential health & safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023

LIC9099 (FAS) - (06/04)

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