198602571-9-14-2021-28-AS-CYEE-C7X3VX-20211018183553

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602571
Report Date: 09/14/2021
Date Signed: 09/14/2021 04:31:10 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
09/02/2021 and conducted by Evaluator LaJean Nicole Spencer

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210902122235

FACILITY NAME:	A AND M ARMOUR HOME CARE		FACILITY NUMBER:	198602571
ADMINISTRATOR:	BRITTANY JONES		FACILITY TYPE:	735
ADDRESS:	2145 ARMOUR STREET		TELEPHONE:	(909) 618-7065
CITY:	POMONA	STATE: CA	ZIP CODE:	91768
CAPACITY:	4	CENSUS: 2	DATE:	09/14/2021
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Brittany Jones, administrator		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Facility staff did not dispense resident's medication as prescribed

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Nicole Spencer conducted a subsequent visit to deliver the findings for the allegations listed above. LPA Spencer met with administrator Brittany Jones and discussed the purpose of today's visit.

The investigation consisted of the following: On 9/9/21, LPA Spencer conducted the initial visit and took a tour of the physical plant and reviewed client medications. LPA interviewed the licensee, administrator, staff #1 (S1), and client #1 (C1). LPA attempted interviews with C2 and C3 but C2 is non-verbal and C3 is in the hospital. During the course of the investigation, LPA interviewed staff #2 (S2) and an employee from C3's placement agency (W1). LPA obtained and reviewed copies of the staff roster, client roster, training logs for medications training on 9/2/21, and C3's MAR logs and hospital discharge papers.

***Narrative continued on LIC9099C***

Substantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: LaJean Nicole Spencer
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021

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-20210902122235

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: A AND M ARMOUR HOME CARE	FACILITY NUMBER: 198602571
	VISIT DATE: 09/14/2021

NARRATIVE

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Regarding the allegation that facility staff did not dispense resident's medication as prescribed, the investigation revealed the following: In interviews, the licensee and administrator stated that there was a medication administration error for C3 due to the fact that C3 was hospitalized several times in August.
Hospital discharge papers show that C3 was hospitalized from 8/3/21-8/10/21, 8/21/21-8/22/21, and 8/23/21-8/30/21.

Staff interviewed stated that there was a misunderstanding about which medications needed to be given to C3 upon discharge from the hospital on 8/10/21. The hospital discharge papers indicated that the next dose of evening medications were to be given by the facility "tonight." Per review of the MAR logs for 8/10/21, S1-S2 initialed for the medications Levertiracetam 750 mg and Clonidine HCL 0.1 mg but they were still in bubble pack. In interviews, S1-S2 stated that they did not dispense the medications on 8/10/21 but initialed their names by accident, thinking that medications were already given by the hospital. W1 stated that W1 observed these medication errors during a semi-annual visit and included the errors in the corrective action plan (CAP) report. The CAP indicated that there were three (3) medications errors: On 8/4/21, Levetiracetam 750 mg AM tablet was popped out of bubble pack even though C3 was still in the hospital, and there was no indication of why it was missing. On 8/10/21, evening medications of Levetiracetam 750 mg and Clonidine HCL 0.1 mg were still in the bubble pack and not dispensed despite hospital discharge papers indicating that evening medications were to be given by the facility that night. C1 stated that staff always give the medications on time, and C2-C3 could not be interviewed at this time.

Based on LPA’s observations, interviews, and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 6, is being cited on the attached LIC 9099D.

An exit interview was conducted and a copy of this report was provided to the Administrator along with the Appeals Rights.

NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: LaJean Nicole Spencer
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210902122235

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: A AND M ARMOUR HOME CARE	FACILITY NUMBER: 198602571
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/14/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/14/2021 Section Cited CCR 80075(b)(5)(B)	1 2 3 4 5 6 7	80075(b)(5)(B) Health-related services: Clients shall be assisted as needed with prescription and non-prescription medications...Once ordered by the physician, the medication is given according to the physician's instructions. This requirement was not met as evidenced by...	1 2 3 4 5 6 7	The administrator stated that staff received medications training from the pharmacy on 9/2/21. In addition, the administrator created a written procedure for giving medications to clients returning from the hospital. The administrator provided a copy of the training logs and the new protocols. The deficiency was cleared prior to the end of the visit.
	8 9 10 11 12 13 14	Based on interviews, observation, and record reviews, the licensee did not ensure that C3's medications were given as prescribed on 8/10/21 upon discharge from the hospital. This poses an immediate health risk to persons in care.	8 9 10 11 12 13 14
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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: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: LaJean Nicole Spencer
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021

LIC9099 (FAS) - (06/04)

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