197609826-5-25-2023-31-AS-NGID-D2UQUX-20240227112923

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609826
Report Date: 02/24/2023
Date Signed: 05/25/2023 08:31:20 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
02/23/2023 and conducted by Evaluator Angela Panushkina

COMPLAINT CONTROL NUMBER: 31-AS-20230223083817

FACILITY NAME:	GARDEN OF PALMS		FACILITY NUMBER:	197609826
ADMINISTRATOR:	GINSBURG, MENACHEM		FACILITY TYPE:	740
ADDRESS:	1025 N FAIRFAX AVE		TELEPHONE:	(323) 656-7900
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90046
CAPACITY:	130	CENSUS: 57	DATE:	02/24/2023
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Nirjara Acharya, Executive Director		TIME COMPLETED:	06:00 PM

ALLEGATION(S):

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Staff mismanaged resident's medication

INVESTIGATION FINDINGS:

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This is the amended copy for previous licensing report dated on 2/24/23. Report was amended to add additional information to support final findings.

At 10:30am Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced complaint visit to investigate the above stated allegation. LPA met with the Executive Director (ED) and explained the reason for the visit.

During the visit, LPA conducted an interview with the Ambassador, ED, Wellness Director (WD), two (2) caregivers and two (2) MedTechs between 10:45am to 12:00pm. Staff denied making any errors on medication record or mismanaging residents medication. LPA spoke with other witnesses involved in R1’s care and supervision, at 12:30pm. An interview of witnesses did not reveal any supporting information. LPA made an attempt to interview seven (7) out of fifty seven (57) residents.
Continue on LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023

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 31-AS-20230223083817

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: GARDEN OF PALMS	FACILITY NUMBER: 197609826
	VISIT DATE: 02/24/2023

NARRATIVE

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Only five (5) out of seven (7) residents were able to communicate and addressed no concerns about their medication assistance.

At 2:44pm, LPA reviewed the facility medication records of the random residents receiving medication assistance by the facility staff. Upon review of medications supply, LPA observed that R1's prescribed medications were centrally stored by the facility. Facility is using Centrally Stored Medication and Destruction Record (CSMDR) form to log resident medications. Upon review of the CSDMR for R1, LPA observed that not all medications were documented properly. With the assistance of facility's MedTech, LPA reviewed total count of R1's "Furosemide" medication left in the bottle. As per doctors instruction/order, R1 was prescribed to take 1-2 tablets per day. The label on the bottle identified that there were 100 pills filled on 01/26/23. However, during the medication count, LPA observed 83 pills were left in a bottle. In addition, LPA did not observe any medication records to identify R1's response to medication assistance. Lastly, MedTech assisting LPA was unable to explain when the last cycle of "Furosemide" started and why is it not clear how many prescribed medications were dispensed to R1.

Based on inspection, observation, interviews and record review, there is sufficient evidence to support the allegation. Therefore, the allegation is Substantiated at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC9099-D)

Exit interview conducted. Appeal rights explained and a copy of this report signed and issued.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20230223083817

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: GARDEN OF PALMS	FACILITY NUMBER: 197609826
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/24/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 05/27/2023 Section Cited CCR 87465(h)(6)F	1 2 3 4 5 6 7	Incidental Medical and Dental Care (h)(6) … (6) The licensee shall be responsible for assuring that a record of centrally stored prescriptions.., which includes (F) Instructions, if any, regarding control and custody of the medication. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator agreed to schedule vendorized medication training for all staff by 05/26/23 and submit to CCL the vendor information and scheduled date of training. Training certifications to be submitted to CCL upon completion.
	8 9 10 11 12 13 14	Based on interview and record review, the licensee did not comply with the section cited above to ensure that CSMDR were properly documented for accountability. R1’s medication was not documented properly. This poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	Administrator agreed to provide Medication Administration Procedure to indicate the steps the facility will take in administering medications to residents and how they are documenting residents response and what information they are using to gain custody and control of medications.
Type A 05/27/2023 Section Cited CCR 87465(C)(2)	1 2 3 4 5 6 7	Incidental Medical and Dental Care (c)(2)Once ordered by the physician the medication is given according to the physician directions. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator agreed to schedule vendorized medication training for all staff by 05/26/23 and submit to CCL the vendor information and scheduled date of training. Training certifications to be submitted to CCL upon completion.
	8 9 10 11 12 13 14	Based on record review and interview, licensee did not comply with the section cited above to ensure that R1’s prescription medication was not dispensed as per doctor’s order. This poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	Administrator agreed to provide Medication Administration Procedure to indicate the steps the facility will take in administering medications to residents and how they are documenting residents response and what information they are using to gain custody and control of medications.

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 Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023

LIC9099 (FAS) - (06/04)

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