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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198205203
Report Date: 06/16/2023
Date Signed: 06/16/2023 03:24:25 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
06/09/2023 and conducted by Evaluator Lourdes Montoya
COMPLAINT CONTROL NUMBER: 11-AS-20230609141712
FACILITY NAME:GLOBAL ELDERLY CARE FACILITY INC.FACILITY NUMBER:
198205203
ADMINISTRATOR:TERESITA CRUZ BAUTISTAFACILITY TYPE:
740
ADDRESS:2009 253RD PL.TELEPHONE:
(424) 250-9710
CITY:LOMITASTATE: CAZIP CODE:
90717
CAPACITY:6CENSUS: 6DATE:
06/16/2023
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:TERESITA BAUTISTATIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff did not provide resident with medications as prescribed.
INVESTIGATION FINDINGS:
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On 6/16/2023, Licensing Program Analyst (LPA) Lourdes Montoya conducted an initial complaint investigation for the allegations listed above. LPA was greeted by House Manager Maricel Campbell. Administrator Teresita Bautista arrived shortly and joined LPA with the visit. LPA explained the purpose of today's visit.

The investigation consisted of the following: LPA toured the physical plant with the House Manager. LPA reviewed R1’s service records (Admission Agreement, Physician’s Report, Appraisal, Medication Administration Records, and hospice records. LPA obtained a copy of the resident and staff rosters and R1’s service records. LPA interviewed four staff (S1-S4) and two (R2 and R3) residents. LPA’s attempts to interview three residents (R1, R4 and R5) were unsuccessful due to their medical conditions. LPA was unable to interview one resident (R6) because R6 is currently in the hospital.

Evaluation Report continue on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023
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 5
Control Number 11-AS-20230609141712
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: GLOBAL ELDERLY CARE FACILITY INC.
FACILITY NUMBER: 198205203
VISIT DATE: 06/16/2023
NARRATIVE
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This page has been amended to revise the first paragraph.
INVESTIGATION REVEALED THE FOLLOWING:

Based on records review, Resident #1 (R1) was admitted to the facility on 5/20/2023. R1’s physician’s report shows R1 is not able to store and administer own medications. R1 is unable to manage own medications but can communicate the need for PRN medications.

Allegation: Staff did not provide resident with medications as prescribed.

It is alleged that staff did not provide resident with medications as prescribed. It was reported that staff has not been giving R1 a medication prescribed by the doctor. Based on interviews conducted, four staff (S1-S4) and two residents (R2 & R3), denied that staff did not provide resident with medications as prescribed. However, based on LPA’s records review, R1’s medication administration records (MAR) in May 2023 shows none of medications was administered. A record of each dose was not maintained in the resident's record. LPA observed R1’s MAR in May 2023 does not list R1’s nonprescription PRN medications. S2 stated S2 administered all R1’s medications since R1 moved into the facility on 5/24/2023 but S2 admitted that S2 forgot to update R1’s MAR and overlooked to list R1’s nonprescription PRN medications.

Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has been met; Therefore, the allegation of: Staff did not provide resident with medications as prescribed” is found to be SUBSTANTIATED.

According to the California Code of Regulations (Title 22, Division 6, Health and Safety Code), the following deficiency has been observed and citation issued (ref. LIC 9099D).

Exit interview was conducted and a copy of the report was provided to Administrator Teresita Bautista.
SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 11-AS-20230609141712
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: GLOBAL ELDERLY CARE FACILITY INC.
FACILITY NUMBER: 198205203
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/17/2023
Section Cited
CCR
87465(c)(3)
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(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can 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:
(3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. This requirement was not met as evidenced by:
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Administrator shall ensure all residents' medication are administered as prescribed and a record of each dose is maintained in the resident's record. Administrator shall conduct a training to staff on Section 87465 of Title 22. POC shall be submitted to CCLD via email to lourdes.montoya@dss.ca.gov.
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Based on LPA’s records review, R1’s medication administration records (MAR) in May 2023 shows none of medications was administered. A record of each dose was not maintained in the resident's record. LPA observed R1’s non-prescription PRN medications are not lised in the MAR for both May and June 2023. S2 stated S2 administered all R1’s medications since R1 moved into the facility on 5/24/2023 but S2 admitted that S2 forgot to update R1’s MAR and overlooked to list R1’s nonprescription PRN medications.
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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.
SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
06/09/2023 and conducted by Evaluator Lourdes Montoya
COMPLAINT CONTROL NUMBER: 11-AS-20230609141712

FACILITY NAME:GLOBAL ELDERLY CARE FACILITY INC.FACILITY NUMBER:
198205203
ADMINISTRATOR:TERESITA CRUZ BAUTISTAFACILITY TYPE:
740
ADDRESS:2009 253RD PL.TELEPHONE:
(424) 250-9710
CITY:LOMITASTATE: CAZIP CODE:
90717
CAPACITY:6CENSUS: 6DATE:
06/16/2023
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:TERESITA BAUTISTATIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not safeguard resident’s medication.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 6/16/2023, Licensing Program Analyst (LPA) Lourdes Montoya conducted an initial complaint investigation for the allegations listed above. LPA was greeted by House Manager Maricel Campbell. Administrator Teresita Bautista arrived shortly and joined LPA with the visit. LPA explained the purpose of today's visit.

The investigation consisted of record reviews. LPA toured the physical plant with the House Manager. LPA reviewed R1’s service records (Admission Agreement, Physician’s Report, Appraisal, Medication Administration Records, and hospice records. LPA obtained a copy of the resident and staff rosters and R1’s service records. LPA interviewed four staff (S1-S4) and two (R2 and R3) residents. LPA’s attempts to interview three residents (R1, R4 and R5) were unsuccessful due to their medical conditions. LPA was unable to interview one resident because R6 is currently in the hospital.

Evaluation Report continue on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Antonine RichardTELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20230609141712
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: GLOBAL ELDERLY CARE FACILITY INC.
FACILITY NUMBER: 198205203
VISIT DATE: 06/16/2023
NARRATIVE
1
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3
4
5
6
7
8
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10
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12
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14
15
16
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32
This page has been amended to revise the first paragraph.
INVESTIGATION REVEALED THE FOLLOWING:

Based on records review, Resident #1 (R1) was admitted to the facility on 5/20/2023. R1’s physician’s report shows R1 is not able to store and administer own medications. R1 is unable to manage own medications but can communicate the need for PRN medications.

Allegation: Staff did not safeguard resident’s medication.

It was alleged that staff did not safeguard resident’s medication. Based on interviews conducted, four staff (S1-S4) and two residents (R2 & R3), denied that staff did not safeguard resident’s medication. Based on LPA's records review of R1's medication administration records (MAR), R1's medications are centrally stored in a locked cabinet in the facility. Based on LPA's observations, there are no missing medications. Based on information gathered, there is no sufficient evidence to corroborate the above allegation.



Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated

An exit interview was conducted with Administrator Teresita Bautista, and a hard copy of report was provided.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Antonine RichardTELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5