198601766-8-28-2021-11-AS-EMAZ-C7CUZE-20210930160126

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601766
Report Date: 08/24/2021
Date Signed: 08/28/2021 02:50:14 PM

Unsubstantiated

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 DR #100
MONTERY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/23/2021 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20210823154604

FACILITY NAME:	OLIVIA ISABEL MANOR		FACILITY NUMBER:	198601766
ADMINISTRATOR:	KUNZ, ANA		FACILITY TYPE:	735
ADDRESS:	21515 S. FIGUEROA STREET		TELEPHONE:	(310) 328-5116
CITY:	CARSON	STATE: CA	ZIP CODE:	90745
CAPACITY:	110	CENSUS: 91	DATE:	08/24/2021
		UNANNOUNCED	TIME BEGAN:	09:14 AM
MET WITH:	MATA FONOPO		TIME COMPLETED:	03:57 PM

ALLEGATION(S):

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Client is not receiving medications as prescribed.
Staff is mishandling a client's medication while in care.

INVESTIGATION FINDINGS:

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On 08/24/21, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced complaint visit at this facility, LPA was greeted by Dario Esguerra and Mata Fonopo the management staff. LPA explained the purpose of today's visit was to gather information on the allegation above. The administrator Ana Kunz was made aware of the visit and was unable to to present duing today's visit.

The investigation consisted of the following: An interview was conducted with Mata Fonopo, (5) staff, and (10) clients. A review of the current staff and resident roster and client #1 (C1) service records and other pertinent records was reviewed. A tour of the physical plant was conducted.

Evaluation Report continues LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021

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 11-AS-20210823154604

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 DR #100
MONTERY PARK, CA 91754

FACILITY NAME: OLIVIA ISABEL MANOR	FACILITY NUMBER: 198601766
	VISIT DATE: 08/24/2021

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: The client is not receiving medications as prescribed.
Staff is mishandling a client's medication while in care.

It is alleged client #1 (C1) is not receiving medications as prescribed. The complainant reports (C1) did not receive his medications as prescribed on 08/20/21. An interview with staff #1-#5 (S1-S5) reports that (C1) had refused his evening medications. The staff (S1-S5) claim clients are given reminders over their room intercoms and overhead speakers when it is time for medication distribution. S1 and S5 claim that (C1) was provided reminders through his room intercom at 8:00 pm; 8:30 pm and 9:15 pm. According to (S1 and S5), (C1) responded to all three calls and said he will come to the medication room but failed to show on time and only appeared 20 minutes passed the 9:30 pm cut off time. The facility has posted in several visible areas the Medication Distribution Schedule and House Rules throughout the facility. The House Rules are provided to each client during admission. In the House Rules contains Medication times are at 8:00 am, 12:00 pm, 4:00 pm, and 8:00 pm. Clients must be medication compliant for their health and safety. According to these scheduled times, the clients have one and a half hours to obtain their medications for each time slot. In an interview with (C1), he admitted he was made aware by (S5) that his evening medications were available between 8 pm – 9:30 pm. (C1) also acknowledged the calls by responding to each call. (C1) claims he overslept and that it was only a one-time occurrence. (C1) claims the staff has never denied him access to his medications. (S1-S5) reports when clients are not responsive during the intercom notifications, staff will check in with the client and make special arrangements. In the case of (C1), he was responsive to all notifications and did not require a person follow up. A review of (C1)’s Medication Administration Records (MAR) revealed that (C1) has been provided all his medications timely, accurately and orderly. There’s no indication that (C1) had any missed dosage aside from 08/20/21 which was logged as client refusal. During the tour of the facility, LPA observed the Medication Schedule and House Rule's signs were posted throughout the facility. In an interview (R1-R10) all claim they had no issues receiving medications as prescribed and had no concerns with Medication Distribution Schedule and House Rules mandated by the facility. Furthermore, they all agreed that the staff provides plentiful notifications throughout the day. All clients interview including (C1) reports the staff are responsive to their needs and services and have no problem with medications, or meals services.

Evaluation Report Continues LIC 9099-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20210823154604

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 DR #100
MONTERY PARK, CA 91754

FACILITY NAME: OLIVIA ISABEL MANOR	FACILITY NUMBER: 198601766
	VISIT DATE: 08/24/2021

NARRATIVE

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It is alleged the staff mishandles client #1 (C1) medications while in care. The complainant claims (C1)’s medications were mishandled and should have not been disposed of when it was not administered. On 08/20/21, (C1) by choice did not take his 8:00 pm medications. According to staff #1 and #4 (S1 and S4), regulations are mandated and that medications are to be disposed of immediately if it is not used due to health and safety concerns. (S4) states the medications are prepackaged in a bubble pack. The medications are sent by the pharmacy and are not in prescription bottle containers. Once each medication is opened, the contents must be used or discarded. (S1) states as a health and safety rule proper disposal of unused prescription drugs must be disposed of immediately to reduce the risk of misuse, accidents, thefts, and deaths. An interview with (C1-C10) all said that that they have had no problems with how the staff handles their medications and their care.

The Department’s investigation consisted of an inspection of the facility, observation, review of (C1’s) service records, incident report, and other pertinent documents relevant to this case, interviews conducted, and found no evidence to support the allegations mentioned above.

Based on the information gathered, there is no evidence to support the allegations: “Client is not receiving medications as prescribed” and “Staff is mishandling a client's medication while in care”.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegations are Unsubstantiated.

No Deficiencies cited under California Code of Regulations Title 22.

An exit interview was conducted with Mata Fonopo and a copy of the report was provided by email.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021

LIC9099 (FAS) - (06/04)

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