191601027-12-21-2023-11-AS-JHAD-D2FU55-20240214141609

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191601027
Report Date: 12/21/2023
Date Signed: 12/21/2023 03:54:05 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/19/2023 and conducted by Evaluator Lizeth Villegas

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20231219105529

FACILITY NAME:	BRITTANY HOUSE		FACILITY NUMBER:	191601027
ADMINISTRATOR:	COLLEN ROZATI		FACILITY TYPE:	740
ADDRESS:	5401 E. CENTRALIA STREET		TELEPHONE:	(562) 421-4717
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90808
CAPACITY:	170	CENSUS: 69	DATE:	12/21/2023
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Administrator Ruth Tistoi		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff mismanaged residents’ medication.

INVESTIGATION FINDINGS:

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On 12/21/23 at 8:45 am, Licensing Program Analyst (LPA) Lizeth Villegas conducted an initial complaint visit regarding the allegation above. LPA met with Administrator Ruth Tistoi as the purpose of today’s visit was explained.
The investigation consisted of the following: On 12/21/23 LPA interviewed Administrator (A1), Staff #1-2 (S1-S2), and obtained copies of the the following: Staff and resident roster and the following documents for R#1, facesheet, identification and emergency information form, admission agrrement, pre-placement appraisal, service plan, physicians report, physicians orders, non-delivery notice of medication, centrally stored medication and destruction report, controlled drug record (PRN) form and controlled drug record for R#1-20.

The investigation revealed the following:

Allegation- Staff mismanaged residents’ medication.
It is being alleged staff mismanaged residents’ medication. On 12/21/23 LPA Villegas interviewed A1

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth Villegas	TELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

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 11-AS-20231219105529

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: BRITTANY HOUSE	FACILITY NUMBER: 191601027
	VISIT DATE: 12/21/2023

NARRATIVE

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regarding the above allegation, A1 acknowledged there have been medication errors observed as A1 took the Administrator role on 12/12/23. Per A1, med room staff were not using the proper forms as a registry was being used, and there were no signatures being produced. A1 continued to state A1 has called the pharmacy to request the correct forms. The last day for former administrator was on 10/30/2023. A1 has an in-service scheduled with the pharmacy to come in and train all med techs and nurses on how to properly administer and document medication. On 12/21/23 LPA Villegas interviewed S1-S2 about the above allegation, 2 of 2 staff interviewed stated there have been medication errors observed.

12/21/23 LPA Villegas conducted a review of controlled drug records and EMAR and confirmed there were discrepancies. The medication review revealed there are (21) residents receiving narcotic medications, only (3) out of (21) were using the correct registry form, there were (4) out of (21) errors in documentation which included missing time, dose count, or signatures. On 12/21/23 there was an admission from the Administrator, 1 med tech and LVN admitting there has been a mismanage of medication.

Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Exit interview conducted with Administrator Ruth Tistoi, appeals rights explained and, a copy of this report was provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth Villegas	TELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 11-AS-20231219105529

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: BRITTANY HOUSE	FACILITY NUMBER: 191601027
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/21/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/22/2023 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	Personal Rights of Residents in All Facilities Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable	1 2 3 4 5 6 7	Administrator will submit a detailed written plan notifying the department what steps will be taken to prevent medications errors from occurring with resident 1 and other residents.
	8 9 10 11 12 13 14	accomodations,furnishings and equipment. Based on medication review facility failed to properply document medication administration, errors included missing time, dose count, or signatures which poses a healthy and safety violation to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth Villegas	TELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5