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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609956
Report Date: 03/01/2023
Date Signed: 03/01/2023 12:13:29 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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
01/26/2023 and conducted by Evaluator Evelin Rios
COMPLAINT CONTROL NUMBER: 31-AS-20230126092252
FACILITY NAME:DESERT WILLOW HOMEFACILITY NUMBER:
197609956
ADMINISTRATOR:LOPEZ, MONIQUEFACILITY TYPE:
735
ADDRESS:4125 W AVENUE DTELEPHONE:
(805) 544-5332
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:4CENSUS: 4DATE:
03/01/2023
UNANNOUNCEDTIME BEGAN:
10:14 AM
MET WITH:TIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff dispensed wrong medication to resident in care
Staff is sleeping during day shift hours
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced subsequent complaint investigation visit. LPA was greeted by staff #1 (S1) and acting administrator Jessica Hatley who granted access to the facility. LPA explained the reason for this visit.

From 10:33 a.m. to 11:30 a.m. LPA interviewed the Administrator and obtained relevant information pertinent to these allegations.

Allegation #1: Staff dispensed wrong medication to resident in care
It is alleged staff members gave resident #1 (R1) the wrong medication which caused R1 to be taken to a hospital for treatment. On 01/26/2023 Community Care Licensing Division (CCLD) received a Special Incident Report (SIR) from the facility self-reporting the incident mentioned in this complaint.
(Continued on LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023
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 3
Control Number 31-AS-20230126092252
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: DESERT WILLOW HOME
FACILITY NUMBER: 197609956
VISIT DATE: 03/01/2023
NARRATIVE
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To investigate this allegation on 01/27/2023 LPA conducted interviews with the administrator, staff, and residents. LPA also obtained records specific to the allegation. Administrator and SIR confirmed on the way back from an outing staff gave R1 medication meant for resident #2 (R2) while in a moving vehicle. According to the Administrator R1 required medical attention and was not themselves immediately after the medication error. In an interview conducted 03/01/2023, Administrator stated corrective action was being processed by human resources. All staff involved, staff #2 (S2), staff #3 (S3), and staff #4 (S4) was assigned mandatory training on medication through the facilities training portal. This is an immediate health and safety risk to clients in care. Based on the information revealed during interviews and record review, the allegation is SUBSTANTIATED at this time.

Allegation #2: Staff is sleeping during shift hours

It is alleged S2 falls asleep on shift. To investigate this allegation on 01/27/2023 LPA conducted interviews with the administrator, staff, and residents. Administrator, staff, and residents revealed S2 falls asleep while on shift. Administrator states it was brought to their attention by other staff and they have had conversations with S2 about falling sleep while on shift. According to the Administrator, they have moved S2 from the evening shift to day shift to help remedy the issue. S2 agreed to move to morning shift. Based on the information revealed during interviews, the allegation is SUBSTANTIATED at this time

Deficiencies cited on LIC 9099 D. Immediate Civil Penalty assessed. Immediate Civil Penalty issued (refer to LIC421IM). Appeal Rights explained. Exit Interview conducted.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20230126092252
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: DESERT WILLOW HOME
FACILITY NUMBER: 197609956
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/17/2023
Section Cited
CCR
80075(b)(5)(B)
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(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5)If the client's physician has stated in writing...providing all of the following requirements are met: (B)...medication is given according to the physician's directions. This requirement is not met as evidenced by:

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Administrator has agreed to in person training conducted by a Registered Nurse and assigned 3 hours of mandatory medication training for staff. Administrator will submit to LPA a schedule of the training for all staff by 03/17/2023 Training certifications to be submitted to LPA upon completion by 04/01/2023.
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Based on SIR provided to CCLD by the facility, as well as staff, resident, and administrator statements, the facility did not comply with the section cited above by not ensuring medications were administered according to physician's orders which poses an immediate health and safety risk to residents in care.
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Type A
03/17/2023
Section Cited
CCR
85065(b)
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(b) The licensee shall employ staff as necessary to ensure provision of care and supervision to meet client needs.
This requirement is not met as evidenced by:
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Administrator moved S1 from the evening shift to day shift as of 01/30/2023. No reports of S1 falling asleep have been reported. POC is cleared as of today.
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Based on interviews conducted with Administrator, staff, and residents the licensee did not comply with the section cited as evidence by corroborating interviews reveal S2 has fallen asleep during on duty shifts which poses 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.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023
LIC9099 (FAS) - (06/04)
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