107209014-9-21-2023-24-AS-SPIY-CW5MGP-20230929093616

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 107209014
Report Date: 09/21/2023
Date Signed: 09/21/2023 01:26:20 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, 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
05/25/2023 and conducted by Evaluator Katie Brown

COMPLAINT CONTROL NUMBER: 24-AS-20230525152545

FACILITY NAME:	MCWEALTH CARE INC. WATHEN HOME		FACILITY NUMBER:	107209014
ADMINISTRATOR:	GAYLORD, APRIL		FACILITY TYPE:	735
ADDRESS:	5943 W WATHEN AVENUE		TELEPHONE:	(559) 458-3947
CITY:	FRESNO	STATE: CA	ZIP CODE:	93722
CAPACITY:	4	CENSUS: 3	DATE:	09/21/2023
		UNANNOUNCED	TIME BEGAN:	09:08 AM
MET WITH:	Ester Jackson		TIME COMPLETED:	01:40 PM

ALLEGATION(S):

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Staff are mismanaging residents medication
Staff are mismanaging residents MARs

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Katie Brown and Kamaldeep Kaur arrived unannounced to conduct a subsequent visit and deliver investigation findings. LPAs met with and explained the reason for the visit with Designee Ester Jackson.

During the visit, LPAs conducted a medication audit of R1, R2 and R3. Interviews were conducted with Designee and S4.

Based on review of R1's MAR and Physician orders, a medication was placed on "hold" 8/23/23 to be resumed on 9/6/23. Staff have documented on the MAR that the medication was given 9/7-9/10/23. 9/11-9/20/23 staff documented that the medication is on hold. Additionally, the Centrally Stored Log documents that the medication card was started 9/16/23 but there are no pills punched out of the card.

See LIC9099C for continuation

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

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 24-AS-20230525152545

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: MCWEALTH CARE INC. WATHEN HOME	FACILITY NUMBER: 107209014
	VISIT DATE: 09/21/2023

NARRATIVE

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The facility does not retain a copy of current physician's order for each resident. R2's Medication Destruction Log was not current. An old medication card was found with inaccurate distribution dates.

The preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 9099-D.

An exit interview was conducted and Plan of Correction was developed. A copy of this report and Appeal Rights were discussed and left with Ester Jackson, whose signature on this form confirms receipt of these documents.

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC9099 (FAS) - (06/04)

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Control Number 24-AS-20230525152545

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: MCWEALTH CARE INC. WATHEN HOME	FACILITY NUMBER: 107209014
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/21/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/22/2023 Section Cited CCR 80075(b)	1 2 3 4 5 6 7	80075 Health Related Services (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Facility has agreed to audit R1's medications and in-service med passers. A written statement will be submitted that confirms this is complete and the names/signatures of the staff in-serviced. Additionally, the medication/documentation plan will be included with dates of completion. This will be submitted by POC date.
	8 9 10 11 12 13 14	Licensee did not ensure that R1 was assisted with medication as ordered by the Physician. MAR documentation states medication was on hold 9/11-9/20/23 which indicates it was not given. This poses an immediate health & safety risk to persons in care.	8 9 10 11 12 13 14
Type B 10/05/2023 Section Cited CCR 80070(b)(10)	1 2 3 4 5 6 7	80070 Client Records (b) Each record must contain information including, but not limited to, the following: (10) Record of current medications, including the name of the prescribing physician, and instructions, if any, regarding control and custody of medications.	1 2 3 4 5 6 7	Facility has agreed to submit a complete list of signed Physician's orders to CCLD by the POC date.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Licensee did not ensure a complete record of Physician's orders is maintained for each resident. This poses a potetial health & safety risk to persons 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.

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC9099 (FAS) - (06/04)

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