198601976-2-13-2024-28-AS-TVAO-D33P34-20240305095651

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601976
Report Date: 02/13/2024
Date Signed: 02/13/2024 02:33:43 PM

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
02/07/2024 and conducted by Evaluator Mary G Flores

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240207115418

FACILITY NAME:	DEL MAR PARK		FACILITY NUMBER:	198601976
ADMINISTRATOR:	DENISE SUTTON		FACILITY TYPE:	740
ADDRESS:	990 EAST DEL MAR BOULEVARD		TELEPHONE:	(626) 577-0215
CITY:	PASADENA	STATE: CA	ZIP CODE:	91106
CAPACITY:	60	CENSUS: 56	DATE:	02/13/2024
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Denise Sutton - Administrator		TIME COMPLETED:	02:48 PM

ALLEGATION(S):

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Facility mismanaged resident's medications.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation regarding the above allegation. LPA met with Denisse Sutton and explained the reason for the visit.

The investigation consisted of the following: LPA requested staff and resident roster, reviewed medication for 7 residents, interview 7 residents and 5 staff, reviewed resident #1(R1)’s and resident #2(R2) medication and requested copies of medication sheet for January and February 2024 for both residents, resident’s notes, medication error report form dated 1/30/24, incident report dated 2/2/24,physician’s report for R1, face sheet, and staff #1(S1)’ medication training.

The investigation revealed the following: Regarding allegation: Facility mismanaged resident's medications. It is alleged that resident took someone else medication and resident is now hospitalize.
(CONTINUED ON LIC 9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024

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-20240207115418

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: DEL MAR PARK	FACILITY NUMBER: 198601976
	VISIT DATE: 02/13/2024

NARRATIVE

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Interviews conducted with residents revealed there have not been incidents in which medication was provided by mistake. Interviews with staff revealed there was a medication error on 1/30/24 in which night shift med tech provide someone else’s medication to R1. Per med-tech (S1), staff picked up the cup at 6:00am in the morning and took the medication to R1. Upon returning to the medication room, nurse ask if the medication was provided and realized that the medication taken was not R1’s medication but R2’s medication, once S1 looked at the label in the cup. R2’s medication was a missed dosed and needed to be disposed in the morning. Per S1 it was a mistake. Facility contacted R1’s physician and responsible party. Per physician’s recommendations facility staff monitored R1 throughout the day for side effects which were reported to physician. On 2/2/24 R1 went to an office doctor visit during the visit R1 reported to have hit R1’s right shin and went out to the hospital due to the hematoma to the right shin and unrelated to the medication error. LPA observed prepared medication for residents and each cup is label with residents’ name and time. Document review revealed facility documented medication error on resident’s note and medication error report form, as well as in the medication sheet. S1 last medication training was provided on 9/25/23, 12/28/23, and 12/30/23.

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 8 are being cited on the attached LIC 9099D.

Exit interview was conducted with Denise Sutton and a copy of this report, LIC 9099D, and appeal rights were provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20240207115418

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: DEL MAR PARK	FACILITY NUMBER: 198601976
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/13/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/14/2024 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411 Personnel Requirements - General: (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidence by:	1 2 3 4 5 6 7	Administrator will provide medication training for S1 which will include shadowing and will submit a copy of training log, topic, description of training, and duration of training by POC due date 2/14/24.
	8 9 10 11 12 13 14	Based on interviews conducted and document review licensee did not ensure that R1 received the correct medication by giving R1 medication that belong to R2 which poses an immediate risk to the health, safety, or personal rights to residents in care.	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.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024

LIC9099 (FAS) - (06/04)

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