198201933-12-6-2023-11-AS-EMAZ-CZKS7W-20240117123811

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198201933
Report Date: 07/05/2023
Date Signed: 12/06/2023 12:28:51 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
06/28/2023 and conducted by Evaluator Jose Calderon

COMPLAINT CONTROL NUMBER: 11-AS-20230628154130

FACILITY NAME:	PALOS VERDES VILLA LLC		FACILITY NUMBER:	198201933
ADMINISTRATOR:	BIENSTOCK, SETH		FACILITY TYPE:	740
ADDRESS:	29661 S WESTERN AVE		TELEPHONE:	(310) 547-9941
CITY:	RANCHO PALOS VERDES	STATE: CA	ZIP CODE:	90275
CAPACITY:	116	CENSUS: 96	DATE:	07/05/2023
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	DIRECTOR LINDA CARDENAS		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff administered wrong medication to resident in care.

INVESTIGATION FINDINGS:

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THIS REPORT SUPERSEDES THE REPORT DATED 07/05/2023 FOR CLARIFYING THE CIRCUMSTANCE FOR THE ALLEGATIONS. ALTHOUGH THIS REPORT SUPERSEDES THE PREVIOUS REPORT THE COMPLAINT INVESTIGATION FINDINGS REMAIN THE SAME: SUBSTANTIATED
Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to Palos Verdes Villa facility on 07/05/2023 and was greeted by Administrator Linda Cardenas (A1). LPA Calderon spoke to A1 prior to entering the facility to conduct a risk assessment. LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations.
The investigation consisted of: LPA Calderon interviewed Administrator Linda Cardenas A1, S1-S3 and interview R1-R2. These interviews were conducted on 07/05/2023. On 07/05/2023 LPA Calderon obtained and reviewed the following: Medication Administration Record (MAR) (dated 6/25/23), incident report (dated 06/25/2023), hospital records (dated 6/25/2023) for R1 and medication training for staff (dated 6/28/23). On 07/05/2023 LPA Calderon toured the common areas and noted medication cart and had staff take LPA Calderon through medication process.
The investigation revealed the following:

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023

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 11-AS-20230628154130

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: PALOS VERDES VILLA LLC	FACILITY NUMBER: 198201933
	VISIT DATE: 07/05/2023

NARRATIVE

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Regarding Allegation #1: Staff administered wrong medication to resident in care.

This complaint alleged staff gave the wrong medication to R1. LPA Calderon conducted an interview with A1. A1 expressed that on 06/25/2023 staff was passing out medications to residents in the dining room area. A1 expressed that staff had taken medication for R1-R2 and put medication in a plastic cup. A1 expressed that staff was pulled away from medication cart due to an emergency and came back to the medication cart to finish passing out residents’ medications. A1 expressed that there was no name on the medication cups and S3 gave R1 the wrong medication. A1 expressed that R2 was given the wrong medication and R2 noticed the error by staff and R2 refused to take another residents medication. LPA Calderon conducted an interview with S1-S3. 2 out of 2 staff said that they were not working at the time of the incident but heard that staff had given the wrong medication to R1. LPA Calderon conducted an interview R2. R2 expressed that R2 was sitting at the same table as R1 when the MedTech came to their table to give them their morning medications. R2 expressed that R2 looked at the medications that were inside R2 plastic cup and R2 knew that R2 had been given the wrong medication to take. R2 expressed that staff told R1-R2 that staff was sorry for the error. On 07/05/2023 LPA Calderon obtained and reviewed incident report (dated 06/25/2023), incident report states that Med Tech gave R1 the wrong medication and was taken to the hospital due to side effects. Obtained and reviewed MAR (dated 06/25/23) for R1, which also noted error in medication on 06/25/2023. Reviewed hospital records (dated 06/25/2023) for R1 which noted accidental ingestion of nontoxic medication. On 07/05/2023 LPA Calderon had S3 take LPA Calderon through the medication process.

Based on LPA Calderon observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation “staff administered wrong medication to resident in care” is found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are cited on the attached LIC 9099D.

An exit interview was conducted with Administrator Linda Cardenas (A1) and a hard copy was provided by hand for records.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20230628154130

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: PALOS VERDES VILLA LLC	FACILITY NUMBER: 198201933
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/05/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/14/2023 Section Cited CCR 87465(c)(2)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care. (c) If the resident's physician has stated in writing that the resident. (2) Once ordered by the physician the medication is given according to the physician's directions.	1 2 3 4 5 6 7	The Administrator will conduct in-service training on Title 22 Regulations 87465 (c)(2) with all staff and submit a copy of the sign-in sheet to LPA by POC date.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on observation the licensee failed to train staff in the proper way to pass out medication to residents in care, which poses a potential health and personal rights risk to residents in care.	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.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023

LIC9099 (FAS) - (06/04)

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