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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 134604423
Report Date: 06/15/2023
Date Signed: 06/15/2023 06:35:55 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/08/2023 and conducted by Evaluator Iby Strong
COMPLAINT CONTROL NUMBER: 08-AS-20230608122943
FACILITY NAME:ROSE CREST ASSISTED LIVINGFACILITY NUMBER:
134604423
ADMINISTRATOR:MARTINEZ, MAGALYFACILITY TYPE:
740
ADDRESS:103 S. HASKELL DR.TELEPHONE:
(760) 960-8404
CITY:EL CENTROSTATE: CAZIP CODE:
92243
CAPACITY:14CENSUS: 9DATE:
06/15/2023
UNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Assistant Administrator Ana Garcia Parra DiazTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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9
Staff did not keep an accurate medication log
Staff did not issue medication as prescribed
Staff altered medication label

INVESTIGATION FINDINGS:
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5
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13
Licensing Program Analysts (LPAs) Iby Strong and Daniel Pena conducted an unannounced visit to open an investigation on the above-mentioned allegations. LPAs identified themselves and disclosed the purpose of the visit. LPAs met with Assistant Administrator Ana Garcia Parra Diaz and discussed the basic elements of the complaint.

On June 6, 2023, Community Care Licensing (CCL) received a complaint alleging staff did not keep an accurate medication log, staff did not issue residents medications are prescribed, and staff altered medication label.

During the investigation, LPA Strong and LPA Pena conducted a facility inspection, conducted interviews, and reviewed facility records. According to allegations, on an unknown date, the medication log did not accurately represent the medications issued to residents.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023
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 6
Control Number 08-AS-20230608122943
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: ROSE CREST ASSISTED LIVING
FACILITY NUMBER: 134604423
VISIT DATE: 06/15/2023
NARRATIVE
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During medication administration record (MAR) review LPA Strong observed Resident 1’s (R1) medication prescription for Medication 1 (M1) prescribed as 90mg tab, 1 every 6 hours. M1 was documented only as a PM medication and there were no other entries for M1. MAR also shows that S1 signed MAR for M1 as received though the matching note states “no medication available”. Additionally, medication 2 (M2) was also signed as received though matching note states “no medication available”.

It was also alleged that residents have not been issued medication as prescribed. During medication review, LPA Strong observed MAR for R1 showing that R1 did not receive a M1 and M2 as prescribed because it was “not available”. Interview with staff corroborated that medication is often not filled timely and residents do not receive medication as prescribed when medication is not available.

Additionally, it was alleged that staff alter prescription medication bottles with their own handwriting. During medication review, LPA Strong observed R1’s medication 3 (M3) with handwriting stating “cut in half”. M3 prescription states 2.5 mg tab 1 tablet by mouth 2x daily, with no instruction to cut in half by pharmacist or physician.

Based on interviews and observations, a preponderance of evidence exists to support the allegation that staff did not keep an accurate medication log, staff did not issue residents medications are prescribed, and staff altered medication label. The allegation is therefore substantiated. A deficiency is cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). An exit interview was conducted with Assistant Administrator Ana Garcia Parra Diaz, to whom a copy of this report, LIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to.
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 08-AS-20230608122943
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ROSE CREST ASSISTED LIVING
FACILITY NUMBER: 134604423
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/29/2023
Section Cited
CCR
80070(a)
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80070 Client Records (a) the licensee shall ensure that a seperate, complete and current record is maintained in the facility for each client.

This requirement was not met as evidenced by:
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7

Licensee agrees to provide vendorized medication administration record training by 6/29/23 and provide LPA with documentation.
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14

Based on observations and records reviewed the licensee did not maintain a complete and current record in 1 of 9 persons in care [R1] which posed a potential Safety risk to persons in care.
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14
Type B
06/29/2023
Section Cited
CCR
87465(c)(2)
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87465 Incidental Medical and Dental Care (c)(2)Once ordered by the physician the medication is given according to the physician's directions.

This requirement was not met as evidenced by:
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7

Lincese agrees to provide vendorized medication training to all staff by 6/29/23 and provide LPA with documentation
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Based on observations and records reviewed the licensee did not follow medication direction provided by the physician in 1 of 9 persons in care [R1] which posed a potential Safety 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: John Rante
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 08-AS-20230608122943
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ROSE CREST ASSISTED LIVING
FACILITY NUMBER: 134604423
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/29/2023
Section Cited
CCR
87465(h)(4)
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87465 Incidental Medical and Dental Care- (h) the following requirement shall apply to medications which are centrally stored: (4)...no person other than the dispensing pharmacist shall alter the prescription label

This requirement was not met as evidenced by:
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7

Licensee agrees to provide medication training to all staff by 6/29/23 and provide LPA with documentation.
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14

Based on observations and records reviewed the licensee altered medication labels in 1 of 9 persons in care [R1] which posed a potential Safety 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: John Rante
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/08/2023 and conducted by Evaluator Iby Strong
COMPLAINT CONTROL NUMBER: 08-AS-20230608122943

FACILITY NAME:ROSE CREST ASSISTED LIVINGFACILITY NUMBER:
134604423
ADMINISTRATOR:MARTINEZ, MAGALYFACILITY TYPE:
740
ADDRESS:103 S. HASKELL DR.TELEPHONE:
(760) 960-8404
CITY:EL CENTROSTATE: CAZIP CODE:
92243
CAPACITY:14CENSUS: 9DATE:
06/15/2023
UNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Assistant Administrator Ana Garcia Parra DiazTIME COMPLETED:
02:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not prevent resident from disrupting other residents sleep.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analysts (LPAs) Iby Strong and Daniel Pena conducted unannounced visit to open an investigation on the above-mentioned allegation. LPAs identified themselves and disclosed the purpose of the visit. LPAs met with Assistant Administrator Ana Garcia Parra Diaz and discussed the basic elements of the complaint.

On June 6, 2023, Community Care Licensing (CCL) received a complaint alleging staff did not prevent R1 from disrupting other residents’ sleep. During the investigation, LPA Strong and LPA Pena conducted a facility inspection, conducted interviews, and reviewed facility records. According to allegations, Resident 1 (R1) is loud and disruptive to other residents during sleep hours. According to interviews with residents present there was no corroborating information provided. Interviews with staff present corroborated that R1 is not disruptive but does have loud behaviors. Staff revealed that R1 often has emotional outburst, but staff attempt de-escalation techniques to keep R1 quiet.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 08-AS-20230608122943
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: ROSE CREST ASSISTED LIVING
FACILITY NUMBER: 134604423
VISIT DATE: 06/15/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
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Based on LPA's interviews, and record reviews there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegation are unsubstantiated. An exit interview was conducted with Assistant Administrator Ana Garcia Parra Diaz, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6