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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600157
Report Date: 08/01/2024
Date Signed: 08/01/2024 09:52:38 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/12/2024 and conducted by Evaluator Sanjay Vaid
COMPLAINT CONTROL NUMBER: 28-AS-20240712154706
FACILITY NAME:GEHM HOMES, INC.FACILITY NUMBER:
198600157
ADMINISTRATOR:MARY ANN HERNANDEZFACILITY TYPE:
735
ADDRESS:19790 SAND SPRING DRTELEPHONE:
(909) 598-4321
CITY:ROWLAND HEIGHTSSTATE: CAZIP CODE:
91748
CAPACITY:4CENSUS: 4DATE:
08/01/2024
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Maryanne Hernandez, AdministratorTIME COMPLETED:
10:15 AM
ALLEGATION(S):
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Staff did not administer medication as prescribed
INVESTIGATION FINDINGS:
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***This licensing report supersedes licensing report (LIC 9099) dated 07/19/24.***

Licensing Program Analyst (LPA) Vaid conducted a follow complaint visit to the facility. Upon arriving at the facility, LPA met with Direct Support Personnal (DSP) Vernanda Guiyab and Administrator, Mary Ann Hernandez who assisted with the visit. LPA discussed and explained the purpose of today’s visit, which was to reissue the citation issued on 07/19/24.

On todays, visit LPA spoke and toured the physical plant along with Maryanne Hernandez.

On 07/19/24, LPA Vaid conducted an initial complaint visit, during visit, LPA Vaid reviewed and obtained client and staff roster, four (4) client admissions agreements, face sheets, physician orders, individual program plans, and medical dispensed sheets (MARS) for the month of December 2023.
Continued on page 9099C.....
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
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 28-AS-20240712154706
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: GEHM HOMES, INC.
FACILITY NUMBER: 198600157
VISIT DATE: 08/01/2024
NARRATIVE
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***This licensing report supersedes licensing report (LIC 9099C) dated 07/19/24.***

LPA toured the physical plant with Administrator Hernandez and did not observe any deficiencies or health and safety concerns. LPA Vaid interviewed Staff 1-2 (S1-S2). LPA observed clients 1-4 (C1-C4) were attending day program, therefore, C1-C4 were not interviewed.

In reference to the allegation: Staff did not administer medications as prescribed, allegedly staff failed to a client their AM medications on 12/07/23. LPA interviewed two (2) of two (2) staff, who reported that staff #1 failed to administer medication to C1 on 12/07/24 and reported the missed medication to the licensing, C1s placement agency and C1s physician, C1s physician advised facility staff to resume C1s AM medications on 12/08/23, and to monitor the C1s health. LPA was unable to interview all four clients as all clients were not present in the facility. Administrator states facility staff administer medications per physician orders, however, Administrator reported that on 12/07/2023, S1 failed to administer medications to C1. LPA Vaid interviewed S1, who acknowledged to having missed administering C1 AM medications 12/07/23. During the visit, LPA observed staff were administering C1-C4 medication for the month of June and July 2024 and did not observe any concerns. The incident for C1s missed medications on 12/07/23, was reported by the Administrator to C1s Regional Center and Licensing on 12/08/23, via fax. On 12/08/23 Regional Center made visit to the facility to investigate the incident and found the facility to be negligent in administering C1s AM medications prescribed by the physician, medication to be dispensed to the C1 daily as prescribed. On 02/08/24, C1s Regional Center staff issued a Corrective Action Plan for the facility, advising facility to review and conduct training of the medications and Medication Administration Records (MARs).

The investigation revealed the following: Staff interviews and LPA Vaid’s review of C1s facility file, including C1s medication, Regional Centers corrective action plan (CAP) dated July 9,2024, revealed that on 12/07/23, S1 did not administer C1’s AM medications as prescribed by the physician for the following medications listed below:
• C1s AM Medication - Aspirin 81mg, take one tablet once a day.
• C1s AM medication- Ferosul 325 mg, take one tablet three times per day.
• C1s AM medication- Glipizide 10 mg, take one tablet twice per day.
• C1s AM medication- Januvia 100 mg, take one tablet once per day.
• C1s AM medication- Lisinopril 10 mg, take one tablet once per day.

CONTINUED on 9099 C.....
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 28-AS-20240712154706
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: GEHM HOMES, INC.
FACILITY NUMBER: 198600157
VISIT DATE: 08/01/2024
NARRATIVE
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  • C1s AM Medication- Loratadine 10 mg, take one tablet once per day.
  • C1s AM medication- Lovastatin 20 mg, take one table once per day.
  • C1s AM medication_ Metaformin 500 mg, take one tablet twice per day.

Based on LPA’s observations, interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapter 1), are being cited on the attached LIC 9099D.

Exit interview was conducted and copy of this report and appeals rights were discussed and given to the Administrator.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 28-AS-20240712154706
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GEHM HOMES, INC.
FACILITY NUMBER: 198600157
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/01/2024
Section Cited
CCR
80075(b)(6)(B)
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Health Related Services 80075(b)- Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.(6)If the client is unable to determine his/her own need for a prescription...and is unable to communicate his/her symptoms clearly,facility staff
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Administrator will provide training to staff members on proper medication administration guidelines and regulations. Corrective Action Plan was conducted on 12/08/2023. LPA received POC for incident.
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designated by the licensee, shall be permitted to assist the client with self-administration.(B)Once ordered by the physician the medication is given according to the physician's directions. This requirement not met as evidence by:
Based on interviews and record review, licensee failed to adminster medication to C1 which presents a potentail health risk to client in care.
California Code of Regulations, (Title 22, Division 6 & Chapter 1), are being cited.
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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.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4