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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200363
Report Date: 08/31/2023
Date Signed: 08/31/2023 12:31:37 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
04/14/2023 and conducted by Evaluator Lisha Holmes
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20230414101116
FACILITY NAME:HODGES CARE HOMEFACILITY NUMBER:
079200363
ADMINISTRATOR:BRITTINI REDDITTFACILITY TYPE:
735
ADDRESS:2624 VIRGINIA AVENUETELEPHONE:
(510) 232-4046
CITY:RICHMONDSTATE: CAZIP CODE:
94804
CAPACITY:6CENSUS: 5DATE:
08/31/2023
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Mya Hodges-Watson, LicenseeTIME COMPLETED:
12:50 PM
ALLEGATION(S):
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Staff failed to administer client's medication as prescribed
INVESTIGATION FINDINGS:
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On 08/31/23 around 11:45 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to deliver the complaint finding for the above allegation. LPA met with Mya Hodges-Watson, Licensee, and explained the purpose of the visit the visit.

During the investigation, LPA interviewed Staff #1 (S1, S2), and all Clients (C1, C2, C3 C4, C5). LPA requested the following documents: Client Roster, Staff Roster, Physician’s Reports, Personnel Record (LIC 500), Individual Program Plan (IPP), Medication Administration Record (MAR), Appraisal Needs and Services Plan, ID/Emergency Contact, Emails, and Care Notes.

For the allegation: Staff failed to administer client's medication as prescribed, LPA reviewed records on 08/29/23 that revealed missing signatures on C1’s pharmacy medication chart for the entire month of March 2023 and April 2023.

Continued on LIC9099...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
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 5
Control Number 15-AS-20230414101116
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: HODGES CARE HOME
FACILITY NUMBER: 079200363
VISIT DATE: 08/31/2023
NARRATIVE
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...continued from LIC9099

On 08/29/23, LPA and S1 discussed C1's file. Missing signatures on C1’s pharmacy medication chart were revealed for the month of March 2023 and April 2023.

Based on LPA’s observations and and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D.

Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided to Licensee.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
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
04/14/2023 and conducted by Evaluator Lisha Holmes
COMPLAINT CONTROL NUMBER: 15-AS-20230414101116

FACILITY NAME:HODGES CARE HOMEFACILITY NUMBER:
079200363
ADMINISTRATOR:BRITTINI REDDITTFACILITY TYPE:
735
ADDRESS:2624 VIRGINIA AVENUETELEPHONE:
(510) 232-4046
CITY:RICHMONDSTATE: CAZIP CODE:
94804
CAPACITY:6CENSUS: 5DATE:
08/31/2023
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Mya Hodges-Watson, LicenseeTIME COMPLETED:
12:50 PM
ALLEGATION(S):
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Staff do not assist client with meeting medical needs
INVESTIGATION FINDINGS:
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On 08/3/123 around 11:45 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to deliver the complaint finding for the above allegation. LPA met with Mya Hodges-Watson, Licensee, and explained the purpose of the visit the visit.

During the investigation, LPA interviewed Staff #1 (S1, S2), and all Clients (C1, C2, C3 C4, C5). LPA requested the following documents: Client Roster, Staff Roster, Physician’s Reports, Personnel Record (LIC 500), Individual Program Plan (IPP), Medication Administration Record (MAR), Appraisal Needs and Services Plan, ID/Emergency Contact, Emails, and Care Notes.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20230414101116
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: HODGES CARE HOME
FACILITY NUMBER: 079200363
VISIT DATE: 08/31/2023
NARRATIVE
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continued from LIC9099A

Allegation: Staff do not assist client with meeting medical needs
UNSUBSTANTIATED

C1’s Physician’s Report dated 08/30/22 did not state medication was prescribed or noted for feet fungus; however, on 04/18/23, W1 which is C1’s Podiatrist (DPM), confirmed that C1 has chronic foot fungus. The medication should be applied twice a day for 2 to 3 weeks then stop. Restart the medication when it worsens again. C1 is to alternate shoes, change socks daily, and put the anti-fungal powder in C1’s shoes occasionally. S1 stated that C1 can be stubborn, and on 02/07/23 C1’s Appraisal Needs and Services Plan further stated that C1 is flat footed, feet roll, toes are closely joined, and moisture is retained. S1 continues to instruct and remind C1 of best practices for foot care. RP stated the client isn’t listening because C1 likes wearing socks. On 11/03/22, S1 refilled the clotrimazole cream with two (2) additional refills to apply twice a day or as needed. On 04/14/23, W1 confirmed that C1 was to use the prescription as directed and would update the prescription directions if needed for the MAR.

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, a copy of this report, and appeal rights provided to Licensee.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 15-AS-20230414101116
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: HODGES CARE HOME
FACILITY NUMBER: 079200363
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/07/2023
Section Cited
CCR
80075(b)(6)(C)
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80075 Health Related Services (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (6)...assist the client with self-administration,...(C) The date and time the PRN medication was taken, the dosage taken,...shall be documented and maintained in the client's facility record.
-This requirement is not met as evidenced by:
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Licensee to review clients medication records, review cited regulation, perform in-service training and send self-certification to CCLD by POC date.
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Based on observation, and record reviews, the licensee did not comply with the section cited above by not documenting C1’s pharmacy medication chart which posed a possible health, safety or personal rights risk to persons 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.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5