191500609-12-3-2020-28-AS-MVAO-BXPP7A-20210128100337

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191500609
Report Date: 12/03/2020
Date Signed: 12/03/2020 03:19:09 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/13/2020 and conducted by Evaluator Tony Vasallo

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20201113153754

FACILITY NAME:	SAN DIMAS RETIREMENT CENTER		FACILITY NUMBER:	191500609
ADMINISTRATOR:	FERNANDA KEY		FACILITY TYPE:	740
ADDRESS:	834 WEST ARROW HIGHWAY		TELEPHONE:	(909) 599-8441
CITY:	SAN DIMAS	STATE: CA	ZIP CODE:	91773
CAPACITY:	343	CENSUS: 184	DATE:	12/03/2020
		UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Fern Key, Administrator		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Staff mishandles resident's medication

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Vasallo initiated a subsequent complaint investigation for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s subsequent complaint investigation was conducted telephonically with administrator, Fern Key The initial tele-visit was conducted on 11/20/20. Staff #1 (S1) and administrator were interviewed at that time.

The investigation consisted of the following: LPA requested and obtained copies of Resident #1’s (R1's) Medication Administration Record (MAR) and staff schedule. Interviews were conducted with 3 staff including the administrator. R1 was also interviewed.

The investigation revealed the following: Administrator and Staff #2 (S2) confirmed an incident occurred with R1’s medication. S2 stated that on 11/8/20 S2 was setting up the medication and handed another staff member R1’s medication. The other staff member walked the medication to R1’s room and both R1 and the other staff member realized there was 1 pill that did not belong to R1. Continued on 9099C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2020

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 28-AS-20201113153754

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SAN DIMAS RETIREMENT CENTER	FACILITY NUMBER: 191500609
	VISIT DATE: 12/03/2020

NARRATIVE

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S2 realized the pill belonged to another resident with a similar name. S2 stated that the medication for the residents with a similar name have been placed on separate medication carts to avoid confusion in the future. R1 was interviewed and confirmed the incident occurred as well.

Based on interviews conducted, the preponderance of evidence standard has been met, therefore the allegation is found to be substantiated. California Code of Regulations, Title 22, citations are being cited on the attached LIC 9099D.

A telephonic exit interview was conducted with Fern Key and a hard copy was provided via email for signature along with appeal rights.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2020

LIC9099 (FAS) - (06/04)

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