198600581-12-11-2023-28-AS-TVAO-CYNPVK-20231219103913

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198600581
Report Date: 12/11/2023
Date Signed: 12/11/2023 01:19:56 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
10/10/2022 and conducted by Evaluator Mary G Flores

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20221010110647

FACILITY NAME:	HOMES FOR LIFE FOUNDATION-HFL CEDAR STREET HOME		FACILITY NUMBER:	198600581
ADMINISTRATOR:	VIDA ANDRADE		FACILITY TYPE:	735
ADDRESS:	11401 BLOOMFIELD, BLDG.305-307		TELEPHONE:	(562) 207-9660
CITY:	NORWALK	STATE: CA	ZIP CODE:	90650
CAPACITY:	38	CENSUS: 30	DATE:	12/11/2023
		UNANNOUNCED	TIME BEGAN:	09:12 AM
MET WITH:	Vida Andrade - Administrator		TIME COMPLETED:	01:32 PM

ALLEGATION(S):

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Client is being over medicated.
Staff did not observe changes in client's condition.
Staff did not seek medical attention for client.
Staff gave responsible person unlabeled medication for client's outing.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent complaint investigation visit regarding the above allegations. LPA met with Vida Andrade and explained the reason for the visit.

The investigation consisted of the following: On 10/11/22 LPA Flores conducted a safe and health check visit and requested Client #1's(C1) documents; physician’s report, medication sheets, appraisal, identification and emergency sheet, personal rights, admission agreement, medication consent forms and physician’s orders. On 12/5/22 A referral to the Investigator Bureau(IB) was submitted as an assignment to obtain medical records for C1's 10/2/22 hospitalization. On 3/13/23 a clinical consult referral was submitted to the Clinical Consult Department. On 4/4/23 and 8/18/23 LPA subpoena additional medical records for C1's 9/3/22 hospitalization. On 9/6/23, and 12/6/23 LPA followed up on subpoena documents. On 12/11/23 LPA conducted additional staff interviews and delivered findings for complaint. (CONTINUED ON LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/11/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20221010110647

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HOMES FOR LIFE FOUNDATION-HFL CEDAR STREET HOME	FACILITY NUMBER: 198600581
	VISIT DATE: 12/11/2023

NARRATIVE

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The investigation revealed the following: Regarding allegation: Client is being over medicated. It is alleged C1 was paranoid, slurred speech, mentally impaired, weight loss, and drowsy from being over medicated on 10/1/22. Interviews conducted with staff who provide medication revealed, staff follow physician’s orders to provide medication to clients, once the medication is discontinued or change medication gets properly destroy and noted on medication sheets. Documents reviewed for C1 revealed the following, medication sheets revealed C1 was on 11 to 13 medications in the months of August through October 2022. Facility recorded changes in three medications due to increase or decrease of dosage between August and September 2022. The changes were noted and adjusted by the psychiatrist providing care at the time, who provided care at least every two weeks. Per clinical review conducted the following was concluded: There are no hospital blood lab results to indicate results of levels of medication on C1’s system for the visits on 9/3/23 or 10/2/23. The medication was adjusted by the physician, and the staff are not capable of adjusting medication. Per medication review there was no medication errors or medication missing to assumed that the facility had dispense over medication to C1 between August to October of 2022.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Regarding allegations: Staff did not observe changes in client's condition and Staff did not seek medical attention for client. It is alleged that on 10/1/22 C1 could not eat or sleep and had dry heaves all night. On 10/2/2022 responsible party(RP) took C1 to the emergency room (ER), and “the doctor said, it was good responsible party took C1 to the ER, as C1 had acute Pancreatitis.” Document review revealed the following: Incident reports note: On 9/3/22 C1 was send to the hospital via 911 due to client not being able to get up from the floor after paramedics’ evaluation. C1 was discharge back to the facility on 9/7/23 with no changes on care. Needs and Care Plan updated on 5/26/22 note mental health changes and goals. However, it does not note any physical health needs or changes. Physician’s orders and consent of medication adjustment sheets were observed from 8/31/22 to 9/27/23 for C1, which track psychiatrist medical care. On 10/1/22 C1’s RP picked C1 up and took C1 for an overnight visit. On 10/2/22 C1’s RP took C1 to the hospital due to observations and health concerns. Medical records review note the following: Hospital intake review for 9/3/22 does not note any treatment or symptoms for pancreatitis issues or other major concerns. C1's hospital intake notes dated 10/2/22, note C1’s intake was due to lack of intake of food and liquids.Based on clinical review conducted, (CONTINUED ON LIC 9099C)

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/11/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20221010110647

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HOMES FOR LIFE FOUNDATION-HFL CEDAR STREET HOME	FACILITY NUMBER: 198600581
	VISIT DATE: 12/11/2023

NARRATIVE

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the facility staff were possibly unaware prior to hospitalization and diagnoses on 10/02/22 that C1 had “hyponatremia, pancreatitis, gastrointestinal issues (obstruction), or dehydration, as these are diagnoses based on a physician’s assessment, lab tests/values, and C1’s clinical presentation during hospitalization.” Such diagnoses must be done by a physician and lab test. Per physician's report dated 9/14/21 C1 was able to communicate own needs. Per interviews conducted clients are seen by a psychiatrist every 2 weeks and by a physician once a month. C1 did not reported to staff any medical issues, or complaints between 9/7/22 and 10/1/22. Although the conditions were present, it is unlikely to assume that the facility staff did not seek for medical attention for C1. As C1 did not complaint or approach the staff requesting medical attention. C1 had refused food but did not complaint of pain or showed other symptoms.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Regarding allegation: Staff gave responsible person unlabeled medication for resident's outing.
It is alleged facility staff gave responsible party medication list and 2 envelopes with C1’s name on each. During interview conducted with responsible party (RP), RP stated that the envelopes were label with C1’s name, the date, and the words evening and bedtime on them. Interview conducted with facility’s administrator and staff revealed upon outings the medication is pop from bubble packs and place on the envelopes labeled to ensure client's take medication during outings for the time a client will be out of the facility. Per facility staff, a home visit medication release form is signed at the time of the medication being provided to take home. Medication is only provided for the days or times the client will be out of the facility. Per medication review, the number of pills matches the number of pills being taken at the time. On 10/1/22 medication was dispensed in the morning and noon by staff and initialed by staff for C1, and notes (HV) for home visit in the evening and bedtime. Per the interview with RP and staff the medication taken homes in the envelopes match the medication sheet and was label for the appropriate times to be provided. Although the medication was not with the original label, the facility listed the medication, and time to be provided at the time C1 was picked up for an outing.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview was conducted with Vida Andrade and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/11/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023

LIC9099 (FAS) - (06/04)

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