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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600544
Report Date: 01/12/2024
Date Signed: 01/12/2024 11:11:52 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
01/11/2024 and conducted by Evaluator Bonnie Tao
COMPLAINT CONTROL NUMBER: 28-AS-20240111094143
FACILITY NAME:VINTAGE HOMEFACILITY NUMBER:
198600544
ADMINISTRATOR:LINDA WILLIAMSFACILITY TYPE:
735
ADDRESS:5418 N. FAIRVALLEYTELEPHONE:
(626) 502-1055
CITY:COVINASTATE: CAZIP CODE:
91722
CAPACITY:6CENSUS: 6DATE:
01/12/2024
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Linda Williams, administratorTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Staff mismanaged client's medication
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Tao conducted an unannounced complaint visit to the facility. Upon arrival, LPA met with Linda Williams, administrator. LPA explained the purpose of the visit to administrator.

During today's visit, LPA obtained a copy of the Staff/Client roster, client#1 (C1) ’s file; interviewed administrator and reviewed client#1 (C1)’s medical records. The investigation consisted of administrator interview and client#1's file review.

In regards to: staff mismanaged client's medication, it was alleged that client#1 (C1) had a medication, Divalproex, which staff dispensed the medication to client on 12/18/23 but did not sign off the record. The investigation revealed that client#1’s medication records, dated 12/18/23, indicated medication, Divalproex, for client #1 was dispensed but medication record was not logged.

(- Continue to LIC9099C -)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024
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 3
Control Number 28-AS-20240111094143
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: VINTAGE HOME
FACILITY NUMBER: 198600544
VISIT DATE: 01/12/2024
NARRATIVE
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Interview with administrator confirmed C1's medication, Divalproex, was dispensed to C1 on 12/18/23 in the morning but did not log in C1’s medication record. Therefore, there was a discrepancy between the medication dispensed and the medication record correctly.

Based on LPAs' file review and interview, the investigation revealed that 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 and Chapter 1 are being cited on the attached LIC 9099D.

Exit interview conducted with Linda Williams, administrator. A copy of this report and appeal rights were provided to Linda.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20240111094143
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: VINTAGE HOME
FACILITY NUMBER: 198600544
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/15/2024
Section Cited
CCR
80075(b)(5)(C)
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A record of each dose is maintained in the client's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the client's response.

This requirement is not met evidenced by:
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Licensee shall provide:

(1) medication administration training to all staff and provide proof to the department;

and
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Medication records review and interview revealed that on 12/18/23, medication, Divalproex, at 7 am for Client #1 was dispensed as prescribed but did not log in medication record.
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(2) review Title 22, Section 80075(b)(5)(C) and provide a signed statement indicating the review of this section detailing how to prevent future medication errors on shift by the POC date
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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: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3