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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602255
Report Date: 02/17/2022
Date Signed: 02/17/2022 10:17:27 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 DR #100
MONTERY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/16/2022 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20220216151652
FACILITY NAME:CALIFORNIA MENTOR - DOMINGUEZ HOMEFACILITY NUMBER:
198602255
ADMINISTRATOR:SIGNEY, RACHELFACILITY TYPE:
735
ADDRESS:214 E DOMINGUEZTELEPHONE:
(909) 483-2505
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY:3CENSUS: 3DATE:
02/17/2022
UNANNOUNCEDTIME BEGAN:
09:09 AM
MET WITH:Claudio RosasTIME COMPLETED:
01:31 PM
ALLEGATION(S):
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Staff failed to administered medication as prescribed.
INVESTIGATION FINDINGS:
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On 02/17/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced complaint visit at this facility, LPA was greeted by Martel Plotnick program manager, and Regina Muriada direct support provider. Muriada contacted Claudio Rosas program director by telephone and explained the purpose of the visit is to gather information regarding the above allegation who later arrived and joined the staff.

The investigation consisted of the following: LPA interviewed staff #1-#3 (S1-S3) and attempted to interview clients #1-#2 (C1-C2), a review of (C1's) service records, Medication Administration Record (MARs) and other pertinent documents associated with this complaint. A tour of the entire facility was conducted.

Evaluation Report Continues on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022
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 11-AS-20220216151652
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: CALIFORNIA MENTOR - DOMINGUEZ HOME
FACILITY NUMBER: 198602255
VISIT DATE: 02/17/2022
NARRATIVE
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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Staff failed to administered medication as prescribed.

It is alleged that staff failed to administered medication as prescribed. The complainant reported there have been too many medication errors for client #1 (C1). The complainant states most recent incidents were on 01/17/22 and 02/14/22 when seizure medications were either missed or given incorrectly. During this visit, staff #1 (S1) program director was interviewed and he indicated there were some medication errors and that incident reports were submitted to Community Care Licensing (CCL). The report also indicated that (C1's) conservators and Harbor Regional Center representatives were also notified. An interview with staff 2 (S2) who admitted and confirmed that she was responsible for the medication errors for both incidents on 01/17/22 and 02/14/22. (S2) claims she takes accountability for her actions and the errors were not done intentionally. (S2) claims on 01/17/22, she unintentionally did not administer two (2) prescribed medications for (C1) as she got distracted as during the time she was providing care for the clients a seismic event (earthquake) occurred and she was distracted and lost focus. The incident on 02/14/22 claims she just wanted to assist with the afternoon staff and gave the two (2) medications to (C1) earlier at 2 pm rather than at 4 pm as prescribed. (S2) claims she notified the program director of the errors immediately. (S1- S3) all reported no other clients were affected by medications errors or hospitalization was necessary due to the medications not being available or given at the wrong time. The Department received incident reports for both events regarding (C1). A review of Medication Administration Records for (C1) verifies the errors on 01/17/22 and 02/14/22. The Department reviewed client #1-#3 (C1-C3) service records and attempted to interview (C1-C2) who were present at the facility and were unable to hold a conversation as a result of their disability. (C3) was not available for an interview as he was at the hospital. Based on the information gathered there's sufficient evidence to corroborate the allegation mentioned above.

Based on observation, interviews, and record reviews, the preponderance of evidence standard has been met, therefore, the above allegation is found to be substantiated. According to California Code Regulations, Title 22 the deficiency issued is documented on LIC 9099-D.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20220216151652
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: CALIFORNIA MENTOR - DOMINGUEZ HOME
FACILITY NUMBER: 198602255
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/18/2022
Section Cited
CCR
80075(b)
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80075 Health Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:
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The Licensee shall ensure that all medications are administered to all the clients as prescribed. The licensee will conduct medication training by a pharmacy or another health care professional. A plan of correction shall be submitted by POC 02/18/22.
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Based on interviews, record reviews, and observation C1 medication records were reviewed for January and February 2022..(S2) admitted to the errors and confirmed the medication were missed and given at incorrect time. This violation possesses an immediate Health and Safety risk to residents in care.
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Note: Physician and responsible party were notified. Regional Center is aware of this incident and Incident report was provided to the department.
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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.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3