198602527-6-19-2023-28-AS-TVAO-CSYLZT-20230620091227

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602527
Report Date: 06/19/2023
Date Signed: 06/19/2023 03:28:14 PM

Unsubstantiated

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
01/11/2021 and conducted by Evaluator Kimberly Ramirez

COMPLAINT CONTROL NUMBER: 28-AS-20210111094558

FACILITY NAME:	FIL-AM FOR SENIORS		FACILITY NUMBER:	198602527
ADMINISTRATOR:	CRISS, CRISTINA		FACILITY TYPE:	740
ADDRESS:	1920 N INDIAN HILL BLVD		TELEPHONE:	(562) 547-6833
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY:	6	CENSUS: 4	DATE:	06/19/2023
		UNANNOUNCED	TIME BEGAN:	03:01 PM
MET WITH:	Toby Miclat		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Resident had access to medications resulting in overdose
Resident did not receive timely medical attention
Resident's medications were mismanaged
Resident's care needs were not being met

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced complaint investigation visit on 06/19/23 to deliver findings regarding the above allegations. LPA Ramirez was met by Administrator Toby Miclat and explained the purpose of the visit.

The investigation consisted of the following: LPA Truman conducted initial compliant visit on 01/19/21 and required a needs further investigation. On 03/21/23, LPA Ramirez conducted an unannounced subsequent complaint visit and required a needs further investigation. Staff (S1-S4), Resident (R2) and Witness #1 (W1) were interviewed. LPA requested and obtained the following documents: LIC 500 Personnel Report, Resident roster, Resident#1 (R1) Emergency ID Page, Physician's Report, Medical records for R1, Admissions Agreement and any other pertinent documentation that may assist with this investigation.

SEE LIC 9099-C for continuation...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023

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-20210111094558

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: FIL-AM FOR SENIORS	FACILITY NUMBER: 198602527
	VISIT DATE: 06/19/2023

NARRATIVE

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The investigation revealed the following: Regarding the above allegations- Resident had access to medications resulting in overdose: It is alleged that R1 had access to medications which resulted in R1 overdosing and being administered Narcan in the ER. R1 was admitted into the facility on 03/20/2020. Physician’s Report dated 2/25/2020 revealed R1 required medication management. Four (4) out of the four (4) staff interviewed deny the above allegation. During physical plant tour of facility on 03/21/23, LPA Ramirez observed centrally stored medications cabinet to contain a padlock and was inaccessible to residents in care. LPA reviewed R1’s Centrally Stored Medication List (LIC 622). Per facility staff, R1 was administered medications as directed by physician and according to label on all prescriptions. LPA Ramirez could not locate any other pertinent documents that suggest facility staff did not adhere to directions on medications list. On 04/05/23, LPA Ramirez sent R1’s LAB results and discharge documents dated 01/07/21 to this departments Program Clinical Consultant. Due to limited information provided at that time, consultants were not able to provide complete interpretation and conclusion of results.

Resident did not receive timely medical attention: It is alleged that R1 did not receive medical attention in a timely manner. Four (4) out of four (4) staff deny this allegation. LPA Ramirez reviewed facility staffing notes dated 01/07/21, 01/25/21 and 01/27/21, which documented R1 requiring medical treatment and intervention/solution. LPA Ramirez reviewed medical treatment and discharge documents dated 01/07/21 for R1. One (1) resident interviewed denied this allegation.

Resident's medications were mismanaged: It is alleged that R1’s medications were mismanaged. LPA Ramirez reviewed R1’s Centrally Stored Medications list. LPA could not locate any discrepancies upon review of medication list. Four (4) out of four (4) staff deny this allegation. One (1) resident interviewed denied this allegation. LPA Ramirez could not locate any other pertinent documents that suggest facility staff were mismanaging R1’s medications.

Resident's care needs were not being met: It is alleged that R1’s care needs were not being met. Four (4) out of four (4) staff deny this allegation. One (1) resident interviewed denied this allegation. LPA Ramirez reviewed staff progress notes that revealed staff administered care to R1 on daily basis.

Although the above allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.
Exit interview was conducted with Toby Miclat and a copy of this report was provided via email due to printer problems.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023

LIC9099 (FAS) - (06/04)

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