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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320433
Report Date: 11/14/2024
Date Signed: 01/09/2025 03:36:01 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
08/09/2024 and conducted by Evaluator Troy Watson
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20240809085534
FACILITY NAME:JEANNE JUGAN RESIDENCEFACILITY NUMBER:
198320433
ADMINISTRATOR:SABINA NAYBERGFACILITY TYPE:
740
ADDRESS:2100 SOUTH WESTERN AVENUETELEPHONE:
(310) 548-0625
CITY:SAN PEDROSTATE: CAZIP CODE:
90732
CAPACITY:86CENSUS: 30DATE:
11/14/2024
UNANNOUNCEDTIME BEGAN:
09:44 AM
MET WITH:Emmanual Ruiz -Director of OperationsTIME COMPLETED:
02:40 PM
ALLEGATION(S):
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Staff did not reorder residents medications timely causing resident to miss medications.
INVESTIGATION FINDINGS:
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On 11/14/2024, Licensing Program Analyst (LPA) Troy Watson conducted an unannounced subsequent complaint visit at this facility and was greeted by the Director of Operations, Emmanuel Ruiz. LPA explained the purpose of the visit is to deliver findings for the allegation listed above and was allowed entrance into the facility.
The investigation consisted of the following: On 08/14/2024 and 09/11/2024 LPA Troy Watson interviewed staff #1-#6 (S1-S6) and interviewed residents #1-#4 (R1-R4). LPA Watson requested, received, and reviewed Resident Census – August 2024 & List, EMAR, Admission Records, Clinical Physician's Orders, Medication and Nutritional Status, Personnel Report, Employee Roster & List, Policy and Procedures, Drug Information Sheet, Medication Administration Records (MARs) and Admission Agreements for R1-R4.

The investigation revealed the following:

CONTINUED ON 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
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-20240809085534
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: JEANNE JUGAN RESIDENCE
FACILITY NUMBER: 198320433
VISIT DATE: 11/14/2024
NARRATIVE
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Allegation: Staff did not reorder medications timely causing residents to miss medication.

On 09/11/2024 the Department audited the facilities Medication Administration Records (MAR) dated September 2024. The facility uses an electronic Mar (eMar). Documents were reviewed for 4 residents, and 4 out of 4 eMAR’s showed blank spaces throughout the record. Per the charting codes given on the eMar, there is a code for each action, so there should be no blanks spaces for daily medications.

On 08/14/2024 and 09/11/2024 LPA Troy Watson interviewed staff #1-#6 (S1-S6). The question asked of the staff was, have any residents run out of medications? Of those interviewed 1 out of 6 staff interviewed stated that they knew of only one resident who ran out of medicine since they have been working there.



On 09/11/2024 LPA interviewed residents #1-#4 (R1-R4). Of those interviewed 4 out of 4 residents confirmed that medication was intermittently distributed to them because of a change in staff. Additionally, LPA interviewed resident 1 – 4, and asked them who reordered their medications. Of those interviewed 2 out of 4 stated their doctors reordered their medications, one out 4 stated that a family member reorders their medications, and one stated that the med-tech reorders their medications.

An Interview with the administrator Sabina Nayberg revealed that one of the residents ran out of medication. The administrator stated that the residents’ doctor was called twice to refill depleted medication but did not respond. The resident whose medication had ran out, received their missing medication later.

CONTINUED ON 9099-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20240809085534
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: JEANNE JUGAN RESIDENCE
FACILITY NUMBER: 198320433
VISIT DATE: 11/14/2024
NARRATIVE
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Based on evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation is found to be SUBSTANTIATED. California code of regulations title 22, division 6, chapter 8 are being cited on the attached LIC 9099D.

An exit interview has been conducted and a copy of the Complaint Report and Appeal Rights was provided to the Director of Operations Emmanuel Ruiz.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 11-AS-20240809085534
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: JEANNE JUGAN RESIDENCE
FACILITY NUMBER: 198320433
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/22/2024
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care
...The licensee shall assist residents with self-administered medications as needed.
This requirment has not been met as evidenced by:
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Administrator will conduct staff medication training. Facility will provide copies of transcripts to CCL via email/fax by POC due dates.
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On 09/11/2024 LPA Troy Watson observed on eMAR that medications had been missed for residents 1-4 for the month of September 2024. This is a potential 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: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4