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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197602038
Report Date: 03/23/2023
Date Signed: 03/23/2023 06:32:42 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/13/2023 and conducted by Evaluator Angela Panushkina
COMPLAINT CONTROL NUMBER: 31-AS-20230313115042
FACILITY NAME:FLOWERS RESIDENTIAL CARE FACILITYFACILITY NUMBER:
197602038
ADMINISTRATOR:RODERICK KIRKFACILITY TYPE:
740
ADDRESS:2762 VISSCHER PLACETELEPHONE:
(626) 797-7996
CITY:ALTADENASTATE: CAZIP CODE:
91001
CAPACITY:6CENSUS: 5DATE:
03/23/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Roderick Kirk, Administrator TIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff do not ensure bathroom is kept clean
Staff do not ensure residents room is free of malodors
Staff do not ensure medication is dispensed as prescribed
Staff are dispensing non prescribed medication to residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced complaint visit to investigate of the above noted allegations. Upon arrival LPA met with the Administrator and explained the purpose of this visit.

LPA conducted a walk through of the facility, interviewed residents and staff and reviewed four (4) residents files and three (3) medication records between 9:30am to 12:00pm. LPA also obtained copies of pertinent documents relevant to the investigation.

Allegation: Staff do not ensure bathroom is kept clean

During todays walk through with S1, at approximatly 11:50am, LPA observed two (2) out of five (5) bathrooms to be dirty and unsanitary. The bathtub on the first floor by the kitchen was dirty and filthy. LPA
Continue on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023
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 6
Control Number 31-AS-20230313115042
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: FLOWERS RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 197602038
VISIT DATE: 03/23/2023
NARRATIVE
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was informed that the bathroom is being used only by the facility visitors. At 11:52am, LPA observed feces on a toilet seat on a second floor in room #6 and it was immediately cleaned by S1. Based on LPA's observation, this allegation is deemed Substantiated at this time.

Allegation: Staff do not ensure residents room is free of malodors
Concerns were expressed the facility smells of urine. During todays investigation LPA and S1 conducted a tour throughout the physical plant, first and second floor. LPA physically observe urine materials in the facility’s physical plant. Although the physical material of urine was not present, in a room #4, there was a strong odor of urine. In addition, Administrator confirmed the strong smell of urine and a presence of flies. Based on the information gathered and LPAs observation, this allegation is deemed Substantiated at this time.

Allegation: Staff do not ensure medication is dispensed as prescribed
LPA spoke with the Administrator and facility two (2) staff members. LPA also reviewed the facility Centrally Stored Medication and Destruction Record (CSMDR) of two (2) random residents receiving medication assistance by the facility staff. Upon review of the medications LPA observed R2's five (5) prescribed new/refill medications (received between 02/23 and 03/23) were not documented on CSMDR. LPA requested an updated CSMDR from the Administrator, but was told that they don't have it. Based on interviews, record review and LPA observation, this allegation is deemed Substantiated at this time.

Allegation: Staff are dispensing non prescribed medication to residents
It was alleged that R1 received four (4) medications not prescribed by the Primary Physician. To investigate this allegation, LPA conducted an interview with the Administrator at 9:50am and Staff #2 (S2) at 10:15am. Interview with S2 revealed that on 03/12/23, during the morning shift between 7:30am - 9:00am, S2 "prepored" the evening medications and left for the day. LPA was informed that the Administrator was scheduled to work that evening. In addition, Administrator confirmed that he failed to double check the medications before administering them to the residents. Finally, interview with the Administrator also reveled that R1's responsible party raised concerns about the medication error on 03/12/23. Based on the information obtained through interviews and observation this allegation is deemed Substantiated.

Deficiency cited on LIC 9099 D. Appeal Rights explained. Copy of this report signed and delivered.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/13/2023 and conducted by Evaluator Angela Panushkina
COMPLAINT CONTROL NUMBER: 31-AS-20230313115042

FACILITY NAME:FLOWERS RESIDENTIAL CARE FACILITYFACILITY NUMBER:
197602038
ADMINISTRATOR:RODERICK KIRKFACILITY TYPE:
740
ADDRESS:2762 VISSCHER PLACETELEPHONE:
(626) 797-7996
CITY:ALTADENASTATE: CAZIP CODE:
91001
CAPACITY:6CENSUS: 5DATE:
03/23/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Roderick Kirk, Administrator TIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
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3
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5
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9
Staff do not ensure resident is accorded toileting assistance
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced complaint visit to investigate of the above noted allegations. Upon arrival LPA met with the Administrator and explained the purpose of this visit.

LPA conducted a walk through of the facility, interviewed residents and staff and reviewed four (4) residents files and three (3) medication records between 9:30am to 12:00pm. LPA also obtained copies of pertinent documents relevant to the investigation.

Allegation: Staff do not ensure resident is accorded toileting assistance

Interview with the Administrator and three (3) staff members revealed that during the time R1 was residing at this facility, the staff was always present and available to assist with toileting needs. Interviews with three (3)
Continue on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 31-AS-20230313115042
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: FLOWERS RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 197602038
VISIT DATE: 03/23/2023
NARRATIVE
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out of five (5) residents, who were able to communicate, also revealed that the staff is alwas available when the need assistance. Based on the information obtained through interviews and observation this allegation is deemed Unsubstantiated.

Exit interview conducted and copy of this report signed and delivered.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 31-AS-20230313115042
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: FLOWERS RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 197602038
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/30/2023
Section Cited
CCR
87303(a)(1)
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87303(a)(1) Maintenance and Operation (a)The facility shall be clean, safe, sanitary and in good repair at all times.(1) the physical plant; floor surfaces in baths, laundry and kitchen areas shall me maintained in a clean, sanitary and odorless condition.
This requirements is not met as evidenced by"
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Licensee agreed to provide housekeeping with proper cleaning chemicals to remove the loud urine odor smell from room #1, #4 and all areas in the facility to maintain an odorless facility. An in-service training will be provided to all staff regarding this deficiency and copy of proof will be submitted by POC date.
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Based on LPAs observation, Licensee did not
comply with the section cited above by not keeping toilet seats in room #6 and residents room #4 clean and sanitary, which poses/posed a potential Health and Safety and Personal Rights risk to persons in care.
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Type B
03/30/2023
Section Cited
CCR
87465(h)(6)A-F
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87465 Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescriptions...

This requirement is not met as evidenced by:
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Administrator agreed to schedule vendorized training for all staff by 03/30/23 and submit to CCL the vendor information and scheduled date of training. Training certifications to be submitted to CCL upon completion by 03/30/23
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Based on record reviews and interviews, licensee did not comply with the section cited above, as facility staff handling medications were not documenting prescribed medications on CSMDR, which poses a potential health and safety rist to residents in care.
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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: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 31-AS-20230313115042
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: FLOWERS RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 197602038
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/25/2023
Section Cited
CCR
87411
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87411 Personnel Requirements-General
(d) All personnel shall be given on the job training... This training and/or related experience shall provide knowledge of and skill in the following... (4) Knowledge required to safely assist with prescribed medications...

This requirement was not met as evidence by:
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Licensee agreed that all personnel (current and or future) will receive the required training. A verification of staff training will be submitted to CCLD by POC date.
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Based on the investigation, the licensee did not comply with the section cited above, Licensee admitted that on 03/12/23 wrong four (4) medications were poured into R1's medications cup and confiscated by R1's family, which poses/posed an immediate health and safety risk to residents in care.
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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: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6