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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191593145
Report Date: 10/08/2021
Date Signed: 10/08/2021 02:18:30 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, 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
09/28/2021 and conducted by Evaluator Joe Katrdzhyan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210928141630
FACILITY NAME:RAMONA GUEST HOME - BELLFLOWERFACILITY NUMBER:
191593145
ADMINISTRATOR:KANIEL, STANLEYFACILITY TYPE:
735
ADDRESS:9555 RAMONA STTELEPHONE:
(562) 867-1002
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY:29CENSUS: 25DATE:
10/08/2021
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Staff / Gloria Zagala
Administrator / Stanley Kaniel		TIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Medication is not administered to client as prescribed
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Joe Katrdzhyan and Nina Galarza conducted an unannounced 10 day complaint visit to this facility. Upon arriving at the facility, LPAs met with Staff / Gloria Zagala and were later joined by the Administrator / Stanley Kaniel who assisted with the visit. LPA Katrdzhyan explained the purpose of today’s visit is to discuss the above mentioned allegation of "Medication is not administered to client as prescribed".

During today's visit, LPA conducted interviews of various persons to include the Administrator and Staff 1. Copies of the MAR (Medication Administrator Record) for months August - October 2021 were reviewed and obtained for Client #1 (C1). Also, the list of medications administered to C1 for the month of October 2021 was reviewed.

(Please see LIC 9099C for additional information)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Joe Katrdzhyan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021
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 28-AS-20210928141630
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: RAMONA GUEST HOME - BELLFLOWER
FACILITY NUMBER: 191593145
VISIT DATE: 10/08/2021
NARRATIVE
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The investigation revealed the following;

Allegation: Medication is not administered to client as prescribed.
After reviewing the MAR for August and September of 2021 for C1, LPA observed discrepancies with the documentation done by staff. LPA discovered that C1 was hospitalized at Los Angeles Community Hospital at Bellflower (LACHB) on 8/27/21 and was discharged back to the facility on 9/2/21. On the MAR for August 2021, Staff failed to initial for the PM dose of Olanzapine 15MG under date 8/26/21. When questioned, Staff was unable to explain what happened and it is unknown at this time if the PM dose was ever administered to C1. On the MAR for dates 9/1/21 and 9/2/21, Staff initialed under the AM and PM dose for medications Quetiapine Fumerate 100MG, Fish Oil 1000MG, Atorvastatin Calcium 20MG and Alonzapine 15 MG as if the medications were administered to C1 but C1 was not at the facility on 9/1/21 and for most of the day on 9/2/21. C1 was discharged from LACHB on 9/2/21 at 12:50PM and did not return to the facility until later during the day on 9/2/21. When questioned, Staff was unable to explain what happened.
During today's visit, LPA reviewed the list of medications administered to C1 for the month of October 2021 and observed the following medication errors;
Clonazepam 1MG was missing from the bubble pack for the AM dose under dates 10/13/21 and 10/24/21 - 10/30/21. Olanzapine 15MG was missing from the bubble pack for the AM dose under dates 10/24/21 - 10/30/21. Clonazepam 1MG for the PM dose had not been administered to C1 under dates 10/4/21 - 10/7/21 but initialed on the MAR as if it was administered to C1. Clonazepam 1MG was missing from the bubble pack for the PM dose under dates 10/15/21 - 10/30/21. Olanzapine 15MG for the PM dose had not been administered to C1 under dates 10/6/21 and 10/7/21 but initialed on the MAR as if it was administered to C1. Olanzapine 15MG was missing from the bubble pack for the PM dose under dates 10/14/21 and 10/15/21 - 10/24/21.
Based on interviews conducted and medications/MARs reviewed, there is sufficient evidence to support the allegation of "Medication is not administered to client as prescribed".

Based on LPA’s observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated.
California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D.
An exit interview was conducted and a copy of this report was provided to the Administrator along with the Appeals Rights.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Joe Katrdzhyan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20210928141630
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: RAMONA GUEST HOME - BELLFLOWER
FACILITY NUMBER: 191593145
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/09/2021
Section Cited
CCR
80075(b)
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Health Related Services. Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:
LPA discovered that C1 was hospitalized at LACHB on 8/27/21 and was discharged back to the facility on 9/2/21. On the MAR for August 2021, Staff failed to initial for the PM dose of Olanzapine 15MG under date 8/26/21. It is unknown at this time if the PM dose was ever administered to C1. On the MAR for dates 9/1/21 and 9/2/21, Staff initialed under the AM and PM dose for medications Quetiapine Fumerate 100MG, Fish Oil 1000MG, Atorvastatin Calcium 20MG and Alonzapine 15 MG as if the medications were administered to C1 but C1 was not at the facility on 9/1/21 and for most of the day on 9/2/21. C1 was discharged from LACHB on 9/2/21 at 12:50PM and did not return to the facility until later during the day on 9/2/21.
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The Administrator will schedule an in-service training on Medication Management for all facility staff in charge of medication administration. Training must be conducted by a pharmacy. A copy of the materials discussed during the training and signatures of all staff present must be forwarded to the CCL office by the POC due date.
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LPA reviewed the list of medications administered to C1 for the month of October 2021 and observed the following medication errors;
Clonazepam 1MG was missing from the bubble pack for the AM dose under dates 10/13/21 and 10/24/21 - 10/30/21. Olanzapine 15MG was missing from the bubble pack for the AM dose under dates 10/24/21 - 10/30/21. Clonazepam 1MG for the PM dose had not been administered to C1 under dates 10/4/21 - 10/7/21 but initialed on the MAR as if it was administered to C1. Clonazepam 1MG was missing from the bubble pack for the PM dose under dates 10/15/21 - 10/30/21. Olanzapine 15MG for the PM dose had not been administered to C1 under dates 10/6/21 and 10/7/21 but initialed on the MAR as if it was administered to C1. Olanzapine 15MG was missing from the bubble pack for the PM dose under dates 10/14/21 and 10/15/21 - 10/24/21. This
poses an immediate health, safety, risk to C1.
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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.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Joe Katrdzhyan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3