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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601815
Report Date: 08/24/2023
Date Signed: 08/24/2023 11:45:15 AM

Substantiated


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
08/16/2023 and conducted by Evaluator Elizabeth Irra
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230816161805
FACILITY NAME:ALFORD HOMEFACILITY NUMBER:
198601815
ADMINISTRATOR:SEAN ESTRELLAFACILITY TYPE:
734
ADDRESS:165 ALFORD STTELEPHONE:
(909) 599-7403
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY:5CENSUS: 4DATE:
08/24/2023
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Anahi Murillo/Assistant AdministratorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff do not administer client's medications as prescribed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Elizabeth Irra conducted the initial visit to investigate the above allegation. LPA met with Anahi Murillo/Assistant Administrator and discussed the purpose of today's visit.

During this investigation, LPA obtained a copy of the client and staff rosters and reviewed C-1's file and obtained relevant documentation. LPA also reviewed the Corrective Action Plan (CAP) dated 08/15/23 developed by San Gabriel Pomona Regional Center. During today's visit, the (CAP) was reviewed with Anahi Murillo (Assistant Facility Administrator) which the findings and (CAP) were agreed upon.

Refer to LIC 9099C for the continuation of this report.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023
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-20230816161805
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: ALFORD HOME
FACILITY NUMBER: 198601815
VISIT DATE: 08/24/2023
NARRATIVE
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Allegation: Staff do not administer client's medications as prescribed. Per Corrective Action Plan (CAP) and confirmation from Anahi Murillo/Assistant Administrator, On 07/27/23 at 1:30AM, a medication error was discovered and reported for C-1. C-1 was not provided with Atorvastatin (20mg at 8PM) and Hydralazine (25mg at 10PM) on 07/26/23. Per CAP, the medications "were still visible in the bubble packs". "It was also seen that the MAR [Medication Administration Record] reflected that Atorvastatin had been administered as ordered". CAP, reviewed documentation and Assistant Facility Administrator interview corroborates this allegation.

Based on LPA’s observations, interviews and records review, the preponderance of evidence standard has been met; therefore, the allegation noted above is found to be SUBSTANTIATED.

Deficiency was observed and cited per California Code of Regulation Title 22 Division 6. Refer to LIC9099D.

Exit interview held, copy of report and Appeal Rights provided to Anahi Murillo/Assistant Administrator

Note: LPA was experiencing technical difficulties during this visit.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20230816161805
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: ALFORD HOME
FACILITY NUMBER: 198601815
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/25/2023
Section Cited
CCR
80075(b)
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Health Related Services-Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This standard is not met as evidence by:
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In-service training on medication administration was completed on 08/19/23 and 08/23/23. POC cleared at the time of this visit.
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On 07/27/23 at 1:30AM, a medication error was discovered and reported for C-1. C-1 was not provided with Atorvastatin (20mg at 8PM) and Hydralazine (25mg at 10PM) on 07/26/23. Per CAP, the medications "were still visible in the bubble packs".
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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: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3