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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607718
Report Date: 02/22/2022
Date Signed: 02/25/2022 09:05:38 AM

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 DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/15/2022 and conducted by Evaluator Pamela Bunker
COMPLAINT CONTROL NUMBER: 11-AS-20220215153134
FACILITY NAME:CENTINELA ASSISTED LIVING CENTREFACILITY NUMBER:
197607718
ADMINISTRATOR:GWENDOLYN CRAIGFACILITY TYPE:
740
ADDRESS:1000 S FLOWER STTELEPHONE:
(310) 674-3216
CITY:INGLEWOODSTATE: CAZIP CODE:
90301
CAPACITY:96CENSUS: 57DATE:
02/22/2022
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Gwen CraigTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Medication error
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced complaint visit on Tuesday, February 22, 2022. Upon arrival at the facility. LPA Bunker called the facility via telephone and conducted a Risk Assessment. Based on the assessment, the facility is clear of COVID-19 infection. LPA Bunker met with Administrator Gwen Craig. LPA Bunker explained the purpose of today's visit.

The investigation consisted of the following: LPA Bunker interviewed staff 1-3 (S1-3), and residents 1-6 (R1-6), LPA Bunker asked questions relevant to the nature of the complaint. At 2:00 P.M., Administrator Gwen Craig and LPA Bunker toured the medication room, observed the resident's medication and MARS in the meds room, and reviewed records. Administration records, documentation, and observation of R1's records observed indicated the facility is administering the resident's medications correctly. However, R1 went home for a home visit with his wife and was given one (1) bottle of R2's medication by mishap.

See continued LIC9099-C page 2
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2022
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 11-AS-20220215153134
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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: CENTINELA ASSISTED LIVING CENTRE
FACILITY NUMBER: 197607718
VISIT DATE: 02/22/2022
NARRATIVE
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Continued LIC9099 page 2

LPA Bunker requested pertinent documentation regarding the above allegation. (Physician's Report, Medical Administration Record, Admission agreement, Appraisal/Needs and Services Plan, Personnel Report, Resident's Roster, Special Incident Report, Corrective Action Memo, and Ongoing In-Service Medication Training)

Allegation: Medication error

Investigation revealed the following: Interviews were conducted with the staff 1-3 (S1-3), and residents 1-6 (R1-R6). The Administrator stated that it is true that one of the Med Techs accidentally gave R1's wife one bottle of Risperidone 1 MG Tab medication that was for R2 when R1 went home with his wife for a weekend visit. Staff stated R1 did not take R2's medication. R1's wife brought R2 medication back to the facility. R2 did not miss taking any of his medications. R2 had an extra supply of medications, VA provides residents with three (3) monthly supplies of medications. Administrator Gwen Craig self-reported the Special Incident Report to all the appropriate agencies in a timely manner within Title 22 Regulations required time frame prior to the complaint allegation. Ms. Craig stated the Med Tech was given a Corrective Action Memo and received ongoing In-Service Medication Training. The Residents interviewed stated they were happy and staff is providing them with the necessary care and supervision, their daily needs are being met and they had no problems at the facility. Residents stated the Med Techs always dispense their medications according to their physician's directions.

Based on LPA’s observations, interviews that were conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC9099-D.

Appeal Rights were discussed, and copies of the Complaint Investigation Report LIC9099, LIC9099-C, and LIC9099-D Confidential Names LIC 811 were provided to Administrator Gwen Craig.


Exit interview conducted.
SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20220215153134
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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CENTINELA ASSISTED LIVING CENTRE
FACILITY NUMBER: 197607718
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/22/2022
Section Cited
CCR
87465(c)(2)
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87465 (c)(2) Incidental Medical and Dental Care:
Once ordered by the physician the medication is given according to the physician's directions. The Med Tech accidentally gave resident 1's wife a bottle of resident 2 Risperidone medication by mistake when he went home with his wife for a weekend visit.
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The deficiency was corrected prior to today's visit. Staff self-reported the special incident report regarding medication error, Med Tech received corrective action and she was retrained on medications.
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The violation poses a potential 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.
SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3