198602067-8-25-2022-28-AS-RORN-CK6TXX-20221013150752

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602067
Report Date: 08/25/2022
Date Signed: 08/25/2022 12:13:50 PM

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
08/17/2022 and conducted by Evaluator Cynthia D Chan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220817132746

FACILITY NAME:	HOUSE OF GRACE LLC		FACILITY NUMBER:	198602067
ADMINISTRATOR:	MICHELLE AGUIRRE		FACILITY TYPE:	740
ADDRESS:	618 RIDGEFIELD DRIVE		TELEPHONE:	(626) 716-1033
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY:	6	CENSUS: 6	DATE:	08/25/2022
		UNANNOUNCED	TIME BEGAN:	09:55 AM
MET WITH:	Venus Calzado, Staff		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Facility does not properly store resident's medications.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint investigation for the allegation listed above. LPA arrived unannounced and met with Staff #1. The Administrator, Michelle Aguirre, was not present at the time of visit, however, the purose of the visit was explained via phone.

The investigation consisted of the following:
LPA toured the facility, reviewed medication for all 6 residents, and conducted interviews with the Administrator and 2 Staff.

The investigation revealed the following:
Regarding allegation - Facility does not properly store resident's medications. The Administrator indicated staff had stored the resident's eye drop in the kitchen refrigerator which was unlocked. The concern has been addressed with the Staff and the medication is no longer stored at the kitchen refrigerator.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2022

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-20220817132746

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: HOUSE OF GRACE LLC	FACILITY NUMBER: 198602067
	VISIT DATE: 08/25/2022

NARRATIVE

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LPA interviewed Staff #1 who admitted to leaving the eye drop in the refrigerator because it was frequently given. Staff #1 stated the eye drop has been moved to the other refrigerator in the garage where residents do not have access. During the visit today, LPA reviewed the medications for all six residents. The only medication to be refrigerated is the eye drop of one of the residents. The rest of the medications are stored and locked in the cabinet located next to the garage door. LPA did not observe any medications stored in the kitchen refrigerator today. The resident's eye drop was stored in the garage area which residents do not access.

Based on interviews conducted, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 8), are being cited on the attached LIC 9099D.

An exit interview was conducted. A copy of this report, Plan of Correction, and appeal rights were provided to the staff.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20220817132746

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: HOUSE OF GRACE LLC	FACILITY NUMBER: 198602067
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/25/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/01/2022 Section Cited CCR 87465(h)(2)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Administrator shall ensure that all medications are stored and locked making them inaccessible to residents. The plan of correction is due by 9/1/22. **This plan of correction has been cleared as of 8/25/22.
	8 9 10 11 12 13 14	Based on interviews, the licensee did not ensure that the eye drop medication was stored and locked in a place not accessible to residents which poses a potential health and safety risk 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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2022

LIC9099 (FAS) - (06/04)

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