197607718-7-29-2021-11-AS-AJKK-C5EUMW-20210730154302

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607718
Report Date: 07/27/2021
Date Signed: 07/29/2021 01:22:19 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 DR #100
MONTERY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/02/2021 and conducted by Evaluator Lourdes Montoya

COMPLAINT CONTROL NUMBER: 11-AS-20210702092228

FACILITY NAME:	CENTINELA ASSISTED LIVING CENTRE		FACILITY NUMBER:	197607718
ADMINISTRATOR:	GWENDOLYN CRAIG		FACILITY TYPE:	740
ADDRESS:	1000 S FLOWER ST		TELEPHONE:	(310) 674-3216
CITY:	INGLEWOOD	STATE: CA	ZIP CODE:	90301
CAPACITY:	96	CENSUS: 45	DATE:	07/27/2021
		UNANNOUNCED	TIME BEGAN:	10:53 AM
MET WITH:	GWENDOLYN CRAIG		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff administered unprescribed medication to resident.

INVESTIGATION FINDINGS:

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On 7/27/2021, Licensing Program Analyst (LPA) Lourdes Montoya conducted a subsequent unannounced complaint visit to continue the investigation and deliver the complaint findings. LPA Montoya called the facility and spoke with Administrator Gwendolyn Craig at around 10:53 am to conduct a risk assessment over the telephone. Based on the assessment, the facility is clear of Covid-19 infection. At around 11:05 am, LPA Montoya met with Administrator Gwendolyn Craig and explained the purpose of the visit.

The investigation consisted of the following: A tour of the facility and interviews with the administrator, staff, and residents on 7/21/2021 and 7/27/21; telephone interview of a witness, review of residents' admission agreement, physician’s report and Appraisal/Needs and Services Plan, Medication Administration Records (MAR), training records and other facility records pertinent to the allegation above.

REPORT CONTINUED IN LIC 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021

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-20210702092228

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
MONTERY PARK, CA 91754

FACILITY NAME: CENTINELA ASSISTED LIVING CENTRE	FACILITY NUMBER: 197607718
	VISIT DATE: 07/27/2021

NARRATIVE

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The investigation revealed the following:

Allegation: Facility staff administered unprescribed medication to the resident.

It is alleged the facility staff administered unprescribed medication to the resident. Based on LPA's records review, Resident #1 was admitted at the facility on 6/8/2018. Preplacement record shows Resident #1 needs help with his medication. According to the Medical Record/Physician’s Report, Resident #1 has dementia; not capable of dispensing his own medication; and not capable of medical decision due to his dementia; a list of his active prescribed medications does not include melatonin. Resident #1’s Medication Administration Record dated 6/1/2021-6/31/2021 does not show Melatonin as one of his prescribed medications. There is no record that melatonin was prescribed to Resident #1 by his doctor. Per LPA’s review of the alleged perpetrator’s (Staff #3) personnel record, she was hired on 4/6/2020 and completed eight hours of hands-on shadowing training and eight hours of other training or instructions.

During LPA’s interview, Resident #1, who is the alleged victim, willingly showed up for interview but refused to answer the questions. LPA was unable to obtain information from him. Residents #2-#10 stated they were not given unprescribed medications and have not heard any other residents given or administered unprescribed medications. However, the Administrator (Staff #1) and the Director of Social Services (Staff #2) admitted that Resident #1 was given two white sleeping pills called melatonin (3 mg) not prescribed to him by this doctor. An incident report dated 7/2/2021 and interview with Staff #1 indicate that a Medication Technician (Staff #3) administered two tablets of melatonin on 6/30/2021 and soon later Resident #1 experienced a side effect that sounds like a hallucination. According to facility’s narrative charting, Staff #3 administered the melatonin to Resident #1 because she was not aware that melatonin is not a house medication.

Report continued in LIC 9099C

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20210702092228

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
MONTERY PARK, CA 91754

FACILITY NAME: CENTINELA ASSISTED LIVING CENTRE	FACILITY NUMBER: 197607718
	VISIT DATE: 07/27/2021

NARRATIVE

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LPA attempted to interview Staff #3 over the telephone, but Staff #3 told LPA that she was not available for interview due to a personal reason. LPA was not able to obtain statements from Staff #3. Staff #1 stated she gave Staff #3 an in-service training on 7/2/2021 regarding mismanagement of medications. LPA’s interview with Resident #1’s Power of Attorney Representative (Witness #1) revealed that Resident #1 experienced a side effect of visual hallucination after taking the melatonin. Witness #1 stated Resident #1 informed her that in his hallucination, he felt like he turned white like a ghost then turned into a black man; he had bumps on his skin, he felt like he was beaten up, and his eyes were swollen. The interviews and records review concur with the above allegation.

Based on LPA’s observations, interviews, and records review, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiency and issued a citation.

An interview was conducted with Gwendolyn Craig, the Administrator, and a hard copy was provided along with Appeal rights.

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20210702092228

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
MONTERY PARK, CA 91754

FACILITY NAME: CENTINELA ASSISTED LIVING CENTRE	FACILITY NUMBER: 197607718
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/27/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/28/2021 Section Cited CCR 87465(d)(1)(2)	1 2 3 4 5 6 7	(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration provided all of the following requirements are met: (1) Facility staff shall contact the resident's physician prior to each dose, describe the resident's symptoms, and receive direction to assist the resident in self-administration of that dose of medication.(2)The date and time of each contact with the physician, and the physician's directions, shall be documented and maintained in the resident's facility record. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	LPA Montoya received a proof that Administrator/Licensee Gwendolyn Craig provided an in-service training on mismanagement of medication to Staff #3 on 7/2/2021. This deficiency has been corrected.
	8 9 10 11 12 13 14	Based on LPA's observations, interviews and records review, licensee failed to ensure staff administers nonprescription PRN medications according to regulations above. Administrator admitted that Staff #3 administered unprescribed melatonin to Resident #1 without contacting resident's physician. The administered medication caused Resident #1 a side effect of hallucination.	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.

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021

LIC9099 (FAS) - (06/04)

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