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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320375
Report Date: 04/16/2025
Date Signed: 04/17/2025 08:18:08 PM

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
02/05/2025 and conducted by Evaluator Yolanda Rosser
COMPLAINT CONTROL NUMBER: 11-AS-20250205121215
FACILITY NAME:CIELAFACILITY NUMBER:
198320375
ADMINISTRATOR:SHRAM, RONYFACILITY TYPE:
740
ADDRESS:17310 WEST VEREDA DELA MONTURATELEPHONE:
(917) 667-5303
CITY:PACIFIC PALISADESSTATE: CAZIP CODE:
90272
CAPACITY:100CENSUS: DATE:
04/16/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator, Rony ShramTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff are not distributing a resident's medication as prescribed
INVESTIGATION FINDINGS:
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On 02/20/2025 LPA Yolanda Rosser and LPM, Eva Alvarez conducted a 10 day-visit at this facility. LPA met with LVN, Wendy Caudle(S1) and explained the purpose of todays visit. LPA was later introduced to Administrator Rony Shram.

Investigation consisted of the following:LPA conducted interviews with Residents (R2-R4) and Staff (S1-S3). LPA obtained R1 Medication Administration Records (Dated: 02/2025 ), Physicians Order for Medication (Dated: 05/17/2024 ), Physicians Report (Dated 06/20/2024), Face Sheet, Resident Appraisal, Identification and Emergency Information. LPA obtained R1 - R4 Physicians Report, Medication Administration Records (Dated 02/2025), and Physicians Order for Medications. LPA obtained copies of Med Tech training. LPA obtained copies of Register of Facility Residents, and Personnel Report.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Yolanda Rosser
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2025
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 11-AS-20250205121215
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: CIELA
FACILITY NUMBER: 198320375
VISIT DATE: 04/16/2025
NARRATIVE
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Investigation Revealed :

Allegation- Staff are not distributing a resident's medication as prescribed

LPA Rosser and LPM Alvarez conducted an interview with Administrator Rony Shram, who stated he conducted an internal investigation, in January 2025, after learning that R1 experienced a Medication Administration error while residing in the facility from July 2024 to February 2025. Administrator Shram reported R1 received (1) tablet of Namenda 10 mg per day after an E-MAR system change occurred in July 2024. R1's physicians order reflected (1) tablet of Namenda 10 mg (2) times per day and the second tablet was not administered after the system change as the new E-MAR did not reflect the order for the second tablet. Administrator Shram self reported the error and submitted an Unusual Incident Report (UIR) to CCL on January 29, 2025. LPA Rosser and LPM Alvarez conducted interviews with LVN Wendy Cuadle (S1), who confirmed R1 received (1) tablet of Namenda 10 mg one time per day after the E-MAR system change occurred in July 2024. LPA Rosser and LPM Alvarez interviewed Residents R2-R4 and found 3 of 3 Residents expressed no issues with staff assistance with Medication Administration. LPA Rosser and LPM Alvarez interviewed Staff/Med Techs ( S2-S3). S2-S3 stated Medication Administration training is provided prior to Med Techs administering medication independently. The Med Techs interviewed stated they administer and record passing medication on the E-MAR. The Med Techs interviewed stated they follow protocols per their training. LPA Rosser and LPM Alvarez obtained and reviewed R1 physician's order (Dated:5/17/24) and R1's Medication Administration Records (Dated August 2024-Febuary 2025). LPA Rosser and LPM Alvarez confirmed R1 received only (1) tablets of Namenda (Generic name: Memantine) 10 mg per day starting in August 2024 - February 2025..

Based on LPA’s observations, interviews, and records reviewed, the preponderance of evidence standard has been met; therefore, the above allegation above is found to be substantiated.

An exit interview was conducted and a copy of this report was provided to Administrator Shram.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Yolanda Rosser
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Citations on this Visit Report are Under Appeal!

Control Number 11-AS-20250205121215
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: CIELA
FACILITY NUMBER: 198320375
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
04/16/2025
Section Cited
HSC
874654(a)(4)
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A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
The licensee shall assist residents with self-administered medications as needed.
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Deficiency was corrected prior to this visit.
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The prepoderance was met as evidenced by: Based on Interviews and Record Reviews staff did not ensure medications were being administered as prescribed per the Physicians Orders.This violation poses a immediate health and safety risk to clients 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 M Alvarez
LICENSING EVALUATOR NAME: Yolanda Rosser
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2025
LIC9099 (FAS) - (06/04)
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