<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600856
Report Date: 08/06/2024
Date Signed: 08/06/2024 11:06:06 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
07/30/2024 and conducted by Evaluator Jewel Baptiste
COMPLAINT CONTROL NUMBER: 28-AS-20240730170811
FACILITY NAME:LARDIZABAL HOMEFACILITY NUMBER:
198600856
ADMINISTRATOR:MARY ANNE NACUAFACILITY TYPE:
735
ADDRESS:212 LONE HILL AVETELEPHONE:
(626) 857-1071
CITY:GLENDORASTATE: CAZIP CODE:
91741
CAPACITY:6CENSUS: 4DATE:
08/06/2024
UNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Administrator Mary Anne Nacua TIME COMPLETED:
11:20 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not give resident medication as prescribed
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 8/6/2024, Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced 10-day complaint visit to investigate the allegation listed above. LPA was allowed entry into the home by Auroa Villarogas (Direct Support Professional (DSP). Mary Anne Nacua (Facility Administrator) arrived at approximately 9:17 a.m., and LPA discussed the purpose of today's visit.

During today’s visit, the administrator stated the following documents will be sent via email: Copy of Staff Roster, Client Roster, Correction action plan (CAP), C1 doctors respondent and blood work, Individual Personal Plan (IPP) for all clients, and Medication Administration Record (MAR) for Client #1 (C1) for the month of July. LPA reviewed medications and Individual Personal Plan (IPP) for all clients with the administrator. Interviews was conducted with the Administrator and a total of 3 staff who shall be referred to as S1 through S3. The facility currently has 4 clients, unfortunately all clients are either non- verbal or has limited communication.

Report Continued on 9099c
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Jewel Baptiste
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024
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-20240730170811
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: LARDIZABAL HOME
FACILITY NUMBER: 198600856
VISIT DATE: 08/06/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Allegation: Staff did not give resident medication as prescribed
It is alleged that S1 was unsure if C1’s medication (Levetiracetam and Lamotrigine) was given as prescribed. According to the Administrator S1 could not remember where the medication went. S1 corroborated with the Administrator adding that they were extremely sick. LPA reviewed the MAR for C1 and observed on 7/17/2024 and 7/18/2024 the MAR was not initial but had an X. On 7/17/2024 San Gabriel Pomona Regional center issued a CAP regarding the medication error. The facility took the following steps of contacting the doctor and getting blood work done for C1. This ensured the client was safe. Since the error occurred the allegation is Substantiated.

Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is 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, a copy of this report and Appeal Rights were provided to Mary Anne Nacua.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Jewel Baptiste
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20240730170811
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: LARDIZABAL HOME
FACILITY NUMBER: 198600856
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/13/2024
Section Cited
CCR
80075(b)(5)(B)
1
2
3
4
5
6
7
Health Related Services. (B) Medications shall be given according to physician's directions.

This requirement is not met as evidence by:
1
2
3
4
5
6
7
Administrator to send incident report to licensing regarding client #1 medication error for C-1. Administator to conduct a staff training on medication and submit proof of training with a written statement as to how the staff will adhere to this regulation to LPA Baptiste by POC due date.
8
9
10
11
12
13
14
Representative conducted an unannounced visit to this facility. During San Gabriel Regional Center visit to this home, it was observed that C-1's medication (Levetricetam and Lamotrigine) was missing. Interviewed staff indicated they are unsure of what happened to the medication.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Jewel Baptiste
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3