<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107206803
Report Date: 07/27/2022
Date Signed: 08/02/2022 11:33:13 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, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/23/2021 and conducted by Evaluator Melinda Medina
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20210423082143
FACILITY NAME:STEPHEN HOUSEFACILITY NUMBER:
107206803
ADMINISTRATOR:SUNDARI SUSAN KENDAKURFACILITY TYPE:
740
ADDRESS:1824 DONNER AVENUETELEPHONE:
(559) 347-9900
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY:6CENSUS: 5DATE:
07/27/2022
UNANNOUNCEDTIME BEGAN:
11:08 AM
MET WITH:Luijean De Castro AbraganTIME COMPLETED:
12:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not have proper training to administer medication
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 7/27/2022, Licensing Program Analyst (LPA) M. Medina arrived at the facility unannounced to deliver findings on the above allegations. LPA was greeted by Caregiver and stated the purpose of the visit.
During the investigation, LPA L. Salazar conducted interviews and records review and it was revealed that staff who is not an appropriately skilled medical professional, was administering morphine to R1 as R1 was unable to self-administer, without the presence of hospice personnel.
Based on records review and interviews, the preponderance of evidence standard has been met therefore the allegation is found to be substantiated. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D.
An exit interview was conducted with Luijean De Castro Abragan, Care Coordinator. A copy of this report and appeal rights were discussed and provided Luijean De Castro Abragan.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022
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 3
Control Number 24-AS-20210423082143
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: STEPHEN HOUSE
FACILITY NUMBER: 107206803
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/28/2022
Section Cited
CCR
87633(b)(4)(B)
1
2
3
4
5
6
7
87633(b)(4)(B)A description of the area of licensee’s responsibility for implementing the plan including, but not limited to, facility staff duties; record keeping; and communication with the hospice agency, resident’s physician, and the resident’s responsible person(s), if any.
1
2
3
4
5
6
7
Licensee shall submit plan by the due date, detailing medication administration limitations for staff who are not skilled medical professionals. The plan shall iclude a date by which all staff will be trained on this section
8
9
10
11
12
13
14
 This description shall include the type and frequency of the tasks to be performed by the facility. (B) The plan shall specify, by name or job function, the licensed health care professional on the hospice agency staff who will control and supervise the storage and administration of all controlled drugs (Schedule II - V) for the hospice client. Facility staff can assist hospice residents with self-medications without hospice personnel being present.

**This requirement was not met as evidenced by staff who is not an appropriately skilled medical professional administering morphine to R1 due to R1 being unable to self-administer, without the presence of hospice personnel.
8
9
10
11
12
13
14
 within 7 days of the POC due date.
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.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/23/2021 and conducted by Evaluator Melinda Medina
COMPLAINT CONTROL NUMBER: 24-AS-20210423082143

FACILITY NAME:STEPHEN HOUSEFACILITY NUMBER:
107206803
ADMINISTRATOR:SUNDARI SUSAN KENDAKURFACILITY TYPE:
740
ADDRESS:1824 DONNER AVENUETELEPHONE:
(559) 347-9900
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY:6CENSUS: 5DATE:
07/27/2022
UNANNOUNCEDTIME BEGAN:
11:08 AM
MET WITH:Luijean De Castro AbraganTIME COMPLETED:
12:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident died as the result of neglect
Staff used inappropriate feeding methods
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 7/27/22 , Licensing Program Analyst (LPA) M. Medina arrived at the facility unannounced to deliver findings on the above allegations. LPA was greeted by Caregiver and stated the purpose of the visit.
During the investigation, LPA L. Salazar conducted interviews and records review that include official Death Report, Pre-placement appraisal (LIC603), Resident R1's Physician’s report (LIC602), Appraisals Needs and Service Plan (LIC625), Admission Agreement, Centrally Stored Medication Destruction Record (CSMDR) and Hospice Care plan.
Records review revealed R1's death was caused by Alzheimer’s disease and there was no indication of neglect or improper feeding methods being used by staff.
Although the allegations may have happened and/or are valid, there is not a preponderance of evidence to prove or disprove that the alleged violations occurred, therefore the allegations are unsubstantiated.
Exit interview conducted with Luijean De Castro Abragan, Care Coordinator and copy of report was left for facility records. No deficiencies cited in reference to these allegations.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3