197606845-3-4-2022-29-AS-KHEN-CCKTLL-20220316144944

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606845
Report Date: 03/04/2022
Date Signed: 03/04/2022 06:08:29 PM

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. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/20/2021 and conducted by Evaluator Emily Peraldi

COMPLAINT CONTROL NUMBER: 29-AS-20210720125916

FACILITY NAME:	FINE GOLD MANOR RETIREMENT		FACILITY NUMBER:	197606845
ADMINISTRATOR:	CRISTINA GOMEZ		FACILITY TYPE:	740
ADDRESS:	10537 MAGNOLIA BLVD.		TELEPHONE:	(818) 761-5777
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91601
CAPACITY:	100	CENSUS: 63	DATE:	03/04/2022
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Cristina Gomez, Administrator		TIME COMPLETED:	06:15 PM

ALLEGATION(S):

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Staff did not administer medications as prescribed.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Emily Peraldi, conducted an unannounced subsequent complaint visit at the facility today. At 2:00 p.m., LPA met with Administrator and explained the reason for the visit.

During the initial visit on 07/27/2021, LPA Emily Peraldi interviewed the Administrator and residents and requested pertinent documents. On 07/27/2021, LPA Peraldi toured the facility and reviewed medications. During the subsequent visit on 02/24/2022, LPA Peraldi and Administrator toured the facility between 11:02 a.m. and 11:25 a.m. On 02/24/2022, LPA Peraldi conducted a medication audit for eight (8) out of sixty-three (63) residents between 11:34 a.m. and 3:05 p.m. On 02/24/2022, LPA Peraldi interviewed residents and staff between 10:29 a.m. and 3:56 p.m. On 02/24/2022, LPA Peraldi also reviewed records at 10:46 a.m. and obtained copies of pertinent documents. On 03/04/2022 between 2:39 p.m. and 4:45 p.m., LPA Peraldi interviewed two (2) staff.

Continued on LIC 9099-C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2022

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 29-AS-20210720125916

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: FINE GOLD MANOR RETIREMENT	FACILITY NUMBER: 197606845
	VISIT DATE: 03/04/2022

NARRATIVE

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Regarding the allegation: Staff did not administer medications as prescribed.
It was alleged that the facility did not administer resident’s medications as prescribed. To investigate on 02/24/2022, LPA Peraldi conducted a medication audit for eight (8) residents out of sixty-three (63) residents. In addition, on 02/24/2022, LPA Peraldi interviewed the Administrator and Staff #1 (S1), who works in the medication room. During the medication audit on 02/24/2022, two (2) out of eight (8) resident medications were observed to be not administered and documented properly. On 02/24/2022 at 1:45 p.m., during the medication audit, LPA Peraldi observed a medication error for Resident #1’s (R1’s) medications. On 02/19/2022, R1’s medication of Memantine HCL 10 MG, one (1) tablet was left inside the morning a.m. bubble packet, indicating that R1 did not receive the correct amount of one (1) tablet by mouth twice daily. During the interview on 02/24/2022 with S1, it was revealed that R1’s medication was dropped on the floor and not given to the resident. Additionally, the interview with S1 revealed that the facility ordered a replacement for the contaminated tablet and that the resident did receive the correct amount of medication. However, there are no documents or notes that demonstrate the replacement tablet was ordered and administered. On 02/24/2022 at 2:40 p.m., LPA Peraldi observed a medication error for Resident #2’s (R2’s) medication. R2’s medication of Olmesartan Medoxomil 20MG Tabs pill count was not accurate with the dates provided. The Olmesartan Medoxomil 20MG Tabs, which contains 30 tablets per bottle, was started on 02/05/2022 and on 02/24/2022 there was 11 tablets left instead of 10.

Based on the information obtained, there is sufficient evidence to support the claim that medications were not being administered to residents per physician’s orders. This allegation is deemed Substantiated at this time.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):

Exit interview conducted and report reviewed with Administrator. A copy of reports and appeal rights will be emailed.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2022

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20210720125916

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: FINE GOLD MANOR RETIREMENT	FACILITY NUMBER: 197606845
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/04/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/11/2022 Section Cited CCR 87465(a)(5)	1 2 3 4 5 6 7	87465(a)(5) Incidental Medical and Dental Care. The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Administrator agreed to do the following: 1. An in-service training to be held with medication technicians. Sign-in sheet and appropriate documents to be submitted by 03/11/2022. 2. Pharmacy to conduct a medication audit by 03/11/2022.
	8 9 10 11 12 13 14	Based on interviews, record review and observations, the licensee did not comply with the section cited above, as the facility failed to assist with Resident #1’s (R1’s) and Resident #2’s (R2’s) self-administered medications per physicians order, which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	3. Going forward to document all medication errors and concerns and provide copies to Administrator and Licensing.
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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: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2022

LIC9099 (FAS) - (06/04)

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