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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197802108
Report Date: 09/26/2024
Date Signed: 09/26/2024 12:56:51 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/17/2024 and conducted by Evaluator Daniel Konishi
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240917104841
FACILITY NAME:PACIFIC BRIDGE ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
197802108
ADMINISTRATOR:SIOKKHING SMITHFACILITY TYPE:
735
ADDRESS:500 S. MCPHERRIN AVETELEPHONE:
(626) 307-8896
CITY:MONTEREY PARKSTATE: CAZIP CODE:
91754
CAPACITY:6CENSUS: 6DATE:
09/26/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:In Lim, AdministratorTIME COMPLETED:
01:10 PM
ALLEGATION(S):
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Client medication errors.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced Initial 10-Day complaint investigation visit regarding the above allegation. LPA discussed the purpose of the visit with Administrator In Lim.

The investigation consisted of the following: LPA requested a copy of staff and client roster. LPA interviewed Admin, Staff #1 (S1) to Staff #2 (S2), and Client #1 (C1) to Client #5 (C5). LPA attempted to interview Client #6 (C6). Client was unable to answer LPA questions. LPA reviewed medication records for C1 to C6. LPA requested copies of personnel report and training list and medication training certificate.

The investigation revealed the following: Regarding allegation: Client medication errors. It is alleged that there were a couple of medication errors during the visit on September 4, 2024.

(Report continued on LIC9099C)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
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 28-AS-20240917104841
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PACIFIC BRIDGE ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 197802108
VISIT DATE: 09/26/2024
NARRATIVE
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 Interviews conducted with staff revealed, 2 out of 3 staff interviewed stated that there was a medication error a three months ago in which for C1 Metformin label was found on the Omega bubble pack administrator stated that she makes these labels and puts them on the bubble pack herself. Additionally, it was discovered on the visit of September 4, 2024, that the facility is not properly logging the administration of Metformin on the MAR as being given. On June 25, 2024 MAR has staff all signed and logged as S3 administrating the medication OX and Vitamin C to C2 but medication still in bubble pack. 5 out of 6 clients interviewed stated there was no medication errors. In addition, ELARC conducted an investigation regarding this allegation which was substantiated.

Based on LPA interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED.

An exit interview was conducted with the Administrator In Lim. A copy of the report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20240917104841
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PACIFIC BRIDGE ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 197802108
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/27/2024
Section Cited
CCR
80075(b)
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(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:
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Administrator will retrain staff that pass out medications and will submit training materials and sign in sheets discussed by the POC due date.
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This requirement is not met with facility during a visit on 09/04/2024, for the C1 Metformin label was found on the Omega medication bubble pack, administrator stated she makes labels and puts them on the bubble pack herself. MAR records had signed and logged as S3 administrating medications to C2 but medication still in bubble pack.This poses an immediate health, safety or personal rights risk to persons 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.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3