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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320232
Report Date: 03/18/2024
Date Signed: 03/19/2024 08:07:34 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/15/2024 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20240315083753
FACILITY NAME:REM CALIFORNIA, LLC - E 213THFACILITY NUMBER:
198320232
ADMINISTRATOR:PAGE, LATORIFACILITY TYPE:
735
ADDRESS:1356 E 213TH STTELEPHONE:
(562) 912-7710
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY:4CENSUS: 3DATE:
03/18/2024
UNANNOUNCEDTIME BEGAN:
09:01 AM
MET WITH:Martel Plonik & Robyn HoodTIME COMPLETED:
04:29 PM
ALLEGATION(S):
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Staff are mismanaging resident's medication.
INVESTIGATION FINDINGS:
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On 03/18/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced complaint visit at this facility, LPA was greeted by Program Director Martel Plotnik and Program Supervisor Robyn Hood. LPA explained the purpose of the visit is to gather information regarding the above allegation.

The investigation consisted of the following: LPA interviewed staff #1-#6 (S1-S6) and interview clients #1-#3 (C1-C3), a review of (C1's) Physician's Report LIC 602 (dated: 08/29/23), Individual Profile, Physician's Order Sheet (dated: 11/22/22) Harbor Regional Center Individual Personal Plan (dated: 01/17/24), and Prescribe Medications Side Effects, Medication Administration Record (MARs) dated: 03/01/24 - 03/18/24 and other pertinent documents associated with this complaint. A tour of the entire facility was conducted. A collateral visit at Cole Vocational Services CSIP Long Beach #306004105.

Evaluation Report Continues on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024
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 4
Control Number 11-AS-20240315083753
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: REM CALIFORNIA, LLC - E 213TH
FACILITY NUMBER: 198320232
VISIT DATE: 03/18/2024
NARRATIVE
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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Staff are mismanaging resident's medication.
It is alleged that staff failed to administer medication as prescribed. The complainant reported client #1 (C1's) 2:00 pm daily prescription medication was not dispensed to (C1) as prescribed. The complainant stated (C1's) Sodium Chloride 1 gram tablet scheduled for 2:00 pm on 03/08/24 was not dispensed and not given to (C1). The complainant reported staff #1 (S1) was responsible for this error and did not document or report it to authorized representatives.

On 03/18/24 between 11:10 am - 12:10 pm, the Department audited the Medication Administration Records (MAR) (dated: 03/01/24 - 03/18/24) and revealed there is no electronic log nor the manual log for (C1's) Sodium Chloride 1 gram tablet on 03/08/24 for between 1:00 pm - 2:00 pm. Evidence revealed the medication Sodium Chloride 1 gram tablet was still tacked in the monthly medication bubble pack for (C1) observed by the Department.

On 03/18/24 between 12:10 pm - 02:20 pm (2) out of (6) staff #1-#6 (S1-S6) were interviewed by the Department were aware of the error. (S1-S2) admitted knowing about the medication error not being dispensed on 03/08/24. (S1) notified (S2) that (S1) discovered prescribed medication for (C1) on 03/08/24 was not dispensed. (S1) reported this happened during morning to afternoon staff shift change. (S1) reported that it was the morning LVN staff's responsibility to dispense the afternoon medication for (C1) before the end of the shift. (S1) stated there was no communication that the LVN staff on 03/08/24 that the afternoon medication for (C1) was not given. (S1) did not follow up or audit the electronic (MAR) until 03/13/24 when (S1) noticed the medication was still in the bubble pack for (C1) and reported it to (S2). (S2) claimed to have reported it to the Program Director staff #4 (S4) on 03/13/24. (S4) denied having any knowledge of the matter and did not report the incident. (S3-S4) both responsible for assisting clients with medications, also did not recognize the medication error on 03/08/24. Although there have been some medication errors in the past, Area Manager staff #6 (S6) was unaware of the medication error on 03/08/24 and none of the care staff reported it. This incident has not been reported to Community Care Licensing, Harbor Regional Center, or Primary Care Physician, according to (S1-S6).

(Evaluation Report continues LIC 9099-C)
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20240315083753
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: REM CALIFORNIA, LLC - E 213TH
FACILITY NUMBER: 198320232
VISIT DATE: 03/18/2024
NARRATIVE
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On 03/18/24 between 09:27 pm - 1:00 pm (2) out of (2) clients #1-#2 (C1-C2) were interviewed by the Department. (C1-C2) reported that there have been no medication errors and (C1-C2) have not missed or refused prescribed medications. (C3) did not want to be interviewed and refused to provide any information.

Between 1:00 pm - 03:00 pm the Department attempted to interview former Licensed Vocational Nurse (LVN) who did not return calls.

Based on evidence gathered, interviews conducted, records reviewed, and photographs, the preponderance of evidence standard has been met; therefore, the allegation of NEGLECT/LACK OF CARE: "Staff is mismanaging resident's medications" is found to be found to be SUBSTANTIATED.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiencies have been observed and a citation issued (ref. LIC 9099D).

An exit interview has been conducted and a copy of the Complaint Report and Appeal Rights was provided to the Program Supervisor Robyn Hood.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 11-AS-20240315083753
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: REM CALIFORNIA, LLC - E 213TH
FACILITY NUMBER: 198320232
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/19/2024
Section Cited
CCR
80075(b)
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80075 Health Related Services
(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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The Licensee shall ensure that all medications are administered to all the clients as prescribed. The licensee will conduct medication training by a pharmacy or another health care professional. A plan of correction shall be submitted by POC 03/19/24 sent to ernand.dabuet@dss.ca.gov
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Based on interviews, record reviews, and observation C1 medication records were reviewed for 03/01/24 through 03/18/24 and observed medication on 03/08/24 was not dispensed. (S1-S2) admitted knowingly aware of the error. This violation possesses an immediate Health and Safety risk to residents in care.
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Type B
03/25/2024
Section Cited
CCR
80061(a)(E)
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80061 Reporting Requirements (a) Each licensee or applicant shall furnish to the licensing agency reports as required by the Department, including, but not limited to... (E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.
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The Licensee will adhere to Title 22 Regulations 80061 and submit a written incident report to CCLD and crossed reference to other authorized agencies. This citation must be corrected by POC 03/25/24 to ernand.dabuet@dss.ca.gov
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This requirement is not met as evidenced by:
Based on information gathered the licensee failed to report this medication error with an incident report to authorized representatives. The facility did not have proof of documentation submitted to CCLD. This violation possed a potential 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: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4