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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 185002415
Report Date: 11/03/2020
Date Signed: 11/03/2020 04:09:01 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/19/2020 and conducted by Evaluator Pheej Cheng
COMPLAINT CONTROL NUMBER: 25-AS-20200219155612
FACILITY NAME:EAGLE LAKE VILLAGEFACILITY NUMBER:
185002415
ADMINISTRATOR:DRUMMOND, LYNNFACILITY TYPE:
740
ADDRESS:2001 PAUL BUNYAN RDTELEPHONE:
(530) 257-6673
CITY:SUSANVILLESTATE: CAZIP CODE:
96130
CAPACITY:76CENSUS: 35DATE:
11/03/2020
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Vicki Cross; AdministratorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Resident was dispensed an anti-psychotic medication without a doctor's order.
INVESTIGATION FINDINGS:
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On 11/3/2020 at 3:30 PM, Licensing Program Analyst (LPA) Cheng conducted an unannounced complaint investigation telephone visit with Administrator Vicki Cross. A telephone/video chat visit was made in compliance to Governor Newsome's Proclamation regarding COVID-19. LPA explained reason for visit.

Based on documents and statements obtained, LPA determined that R1 was was given the medication Fluphenazine without having a doctor's order on hand. E-mail correspondence show that the pharmacy that the facility uses had mistakenly duplicated the medication Fluphenazine from another resident onto R1.

Continuation on LIC 9099C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Pheej ChengTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2020
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 25-AS-20200219155612
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: EAGLE LAKE VILLAGE
FACILITY NUMBER: 185002415
VISIT DATE: 11/03/2020
NARRATIVE
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Per Plan of Corrections documents received on 1/20/2020, facility has a "three-way" check system in place to reduce medication error. Per LPA's observation, the "three-way" check was not followed as there was no doctors order on hand, medication was approved via electronic Medication Administration Record (eMAR) without a doctor's order, and accepted at facility without verification. Facility also failed to provide a stamp and signatures verification in each step of the "three-way" check system.

Facility's eMAR indicates that S1 gave R1 Fluphenazine on 1/16/2020 at 9:05 AM with a notation that medication was received from pharmacy and given. Facility's eMAR also indicates that on 1/16/2020 at 9:40 AM, S2 had went into the system to change the time of the medication to be administered and S2 confirmed that a review of doctor's order was not verified as S2 assumed the "three-way" check was completed.

Based on LPA information obtained during investigation, 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), are being cited on the attached LIC 9099D.

Exit interview conducted and two copies of report will be mailed requesting for a returned copy with a wet signature.

SUPERVISOR'S NAME: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Pheej ChengTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 25-AS-20200219155612
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: EAGLE LAKE VILLAGE
FACILITY NUMBER: 185002415
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/03/2020
Section Cited
ILS
87465(e)
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Incidental Medical and Dental Care - For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician…This requirement was not met as evidenced by:
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Licensee presented to LPA a Corrective Action Plan that was implemented by the facility. Since implementing the plan, medication errors have reduced.
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Based on statements and documents obtained, Licensee did not have a written order from a physician for 1 of 1 resident which poses an immediate health and safety risk to resident in care.
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LPA presented the plan to LPM Rayna Bryson and both agreed that it would sufficient to clear the deficiency. Deficiency has been cleared.
ILS
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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.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Pheej ChengTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 3