157208773-8-5-2021-24-AS-SPIY-C6WUUZ-20210916155421

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 157208773
Report Date: 08/04/2021
Date Signed: 08/05/2021 06:25:15 PM

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
07/23/2021 and conducted by Evaluator Shawna Doucette

COMPLAINT CONTROL NUMBER: 24-AS-20210723084805

FACILITY NAME:	JASMIN TERRACE AT BAKERSFIELD		FACILITY NUMBER:	157208773
ADMINISTRATOR:	ELECO, RAMONA D.		FACILITY TYPE:	740
ADDRESS:	5400 STINE ROAD		TELEPHONE:	(661) 398-8802
CITY:	BAKERSFIELD	STATE: CA	ZIP CODE:	93313
CAPACITY:	99	CENSUS: 81	DATE:	08/04/2021
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Ramona Eleco, Administrator		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff failed to administer resident's medication as prescribed.
Facility falsifying residents’ logs.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analysts (LPAs) Lady Cabrera and Shawna Doucette contacted the facility to commence a complaint investigation. LPA conducted a visit and took COVID-19 pre-cautionary measures. LPA identified herself and explained the purpose of the visit and the elements of the allegations with Administrator Ramona Eleco. LPAs delivered findings to Administrator.

LPAs reviewed pharmacy log provided by Mercy Pharmacy. LPAs reviewed MARS log. Facility did not have a centrally stored log for residents medications to review. LPAs reviewed Resident's (R1) and (R2) medications. LPA interviewed Medication Technician and Administrator.

Based on records review and staff interviews it was found that R1 and R2 missed medications. Pharmacy log stated medication for R1 was last refilled on 5/3/21 and not refilled again until 7/12/21. Mercy Pharmacy Medication is administered from pharmacy in a count of 30 pills. MARS log shows pills are being administered, however it does not reflect the amount of pills prescribed.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Shawna Doucette	TELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2021

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-20210723084805

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: JASMIN TERRACE AT BAKERSFIELD	FACILITY NUMBER: 157208773
	VISIT DATE: 08/04/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Based on facility records, it was discovered that staff are signing off on the MARS log indicating medication was administered, which does not reflect the amount prescribed by pharmacy records.

Based on LPAs observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division & Chapter number, are being cited on the attached LIC 9099D.

Plan of correction and appeal rights was reviewed with Licensee.

An exit interview was conducted with Administrator Ramona Eleco and a copy of this report was provided.

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Shawna Doucette	TELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 24-AS-20210723084805

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: JASMIN TERRACE AT BAKERSFIELD	FACILITY NUMBER: 157208773
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/04/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/05/2021 Section Cited CCR 87465(a)(5)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:	1 2 3 4 5 6 7	Plan of Correction POC Licensee agrees to provide medication training to staff to include centrally stored medication log and the administration of medications.
	8 9 10 11 12 13 14	(5) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by Based on records review and interviews, Licensee did not administer R1 and R2's medications as prescribed which poses an immediate health, safety, or personal rights risk to persons in care.	8 9 10 11 12 13 14
Type A 08/05/2021 Section Cited CCR 87207	1 2 3 4 5 6 7	\ 87207 False Claims No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement was not met as evidenced by: Based on pharmacy records review and facility records review	1 2 3 4 5 6 7	Plan of Correction POC Licensee agrees to provide a written plan of the understanding of the regulation and how it will be met in the future.
	8 9 10 11 12 13 14	Licensee is signing off on the MARS log indicating medication were administered, which does not reflect the amount prescribed by pharmacy records, which poses an immediate health, safety, or personal rights risk to persons in care which poses an immediate health, safety, or personal rights 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.

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Shawna Doucette	TELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3