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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602624
Report Date: 09/22/2021
Date Signed: 09/22/2021 11:31:13 AM

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
09/16/2021 and conducted by Evaluator Elizabeth Irra
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210916123316
FACILITY NAME:SWEET HOLLANDER HOMEFACILITY NUMBER:
198602624
ADMINISTRATOR:ARQUERO, LORNAFACILITY TYPE:
735
ADDRESS:3074 HOLLANDER STTELEPHONE:
(909) 445-0021
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY:6CENSUS: 6DATE:
09/22/2021
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:S-1TIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Staff did not dispense client's medication as prescribed by physician.
Staff did not ensure that medication was locked.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced initial 10-day complaint visit to investigate the above allegations. LPA was allowed entry by S-1. LPA explained the purpose of today's visit.

The following was obtained during today's visit:
Staff Roster, Client Roster, Certificate of Completion for medication administration for staff and relevant documentation for Client #1 (C-1) and Client #2 (C-2).

During today's visit, LPA interviewed S-1 and reviewed and obtained documentation from C-1's and C-2's file.

Refer to LIC 9099C for the continuation of this report;
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021
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 4
Control Number 28-AS-20210916123316
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: SWEET HOLLANDER HOME
FACILITY NUMBER: 198602624
VISIT DATE: 09/22/2021
NARRATIVE
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Allegation: Staff did not dispense client's medication as prescribed by physician. During today's visit, LPA interviewed S-1 and reviewed and obtained documentation from C-1's and C-2's file. Per S-1 interview, on 09/07/21, during an unannounced visit conducted by San Gabriel Pomona Regional Center, the following was discovered: C-1’s medication- Levothyroxine sodium 175mg for hypothyroidism, Vitamin D-3 2000 IU for vitamin deficiency GNP vitamin B-1 100mg for supplement, Montelukast Sodium 10mg for allergic rhinitis, Quantiapine Fumarate for mood stabilization and Divalproex Sodium Dr 500mg for mood stabilization was still inside the medication bubble pack (not administered). Per S-1 interview, C-1 was having a behavior on 09/07/21 (same day) and S-1 thought the medication was administered to C-1. For C-2, half (1/2) of a tablet of Metformin (for diabetes) was stuck inside the bubble pack. Per S-1 interview, S-1 had an oversight and did not realize the half (1/2) tablet was still inside the bubble pack. Per S-1 interview, since this incident, the following has been implemented: Medication Administration Training provided by a Pharmacy and a Medication Verification method in which a secondary staff verifies and ensures medication has been administered as prescribed. Additionally, per S-1, the prescribing Physician was notified of the medication errors. Based on staff interview and documentation review, this allegation is corroborated.

Allegation: Staff did not ensure that medication was locked. During today's visit, LPA interviewed S-1 and reviewed and obtained documentation from C-1's and C-2's file. Per S-1 interview, on 09/07/21, during an unannounced visit conducted by San Gabriel Pomona Regional Center, the following was discovered: The small refrigerator that stores C-3’s insulin (for diabetes) was not locked. Per S-1 interview, the lock was hanging (unlocked) on the padlock latch. Per S-1 interview, staff were reminded to ensure the lock on the small refrigerator used to store medication is locked at all times. Additionally, a Medication Verification method in which a secondary staff verifies and ensures medication has been administered as prescribed and ensures the refrigerator that stores medication remains locked at all times has been implemented. Based on staff interview, this allegation is corroborated.

Based on LPA’s observations and interview which was 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 1 are being cited. Refer to attached LIC 9099D.

Exit interview conducted, a copy of the report and appeal rights were provided to S-1.

NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 28-AS-20210916123316
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: SWEET HOLLANDER HOME
FACILITY NUMBER: 198602624
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/22/2021
Section Cited
CCR
80075(b)(5)(B)
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80075(b)(5)(B) Health Related Services (b)Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility
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Per S-1 interview, since this incident, the following has been implemented: Medication Administration Training provided by a Pharmacy and a Medication Verification method in which a secondary staff verifies and ensures medication has been administered as prescribed. .
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staff designated by the licensee shall be permitted to assist the client with self-administration, providing all of the following requirements are: (B) Once ordered by the physician the medication is given according to the physician's directions.

This standard is not met as evidence by:
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Additionally, per S-1, the prescribing Physician was notified of the medication errors. POC CORRECTED.
Type A
09/22/2021
Section Cited
CCR
80075(b)(5)(B)
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THIS IS A CONTINUATION OF 80075(b)(5)(B) Health Related Services. Per S-1 interview, on 09/07/21, during an unannounced visit conducted by San Gabriel Pomona Regional Center, the following was discovered: C-1’s medication- Levothyroxide sodium 175mg for hypothyroidism, Vitamin D-3 2000 IU for vitamin deficiency GNP vitamin B-1 100mg
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for supplement, Montelukast Sodium 10mg for allergic rhinitis, Quantiapine Fumarate for mood stabilization and Divalproex Sodium Dr 500mg for mood stabilization was still inside the medication bubble pack (not administered).
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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: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 28-AS-20210916123316
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: SWEET HOLLANDER HOME
FACILITY NUMBER: 198602624
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/22/2021
Section Cited
CCR
80075(k)(1)
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80075 (k)(1) Health Related Services: (k) The following requirements shall apply to medications which are centrally stored:(1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
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Per S-1 interview, staff were reminded to ensure the lock on the small refrigerator used to store medication is locked at all times. Additionally, a Medication Verification method in which a secondary staff verifies and ensures medication has been administered as prescribed and ensures the refrigerator that stores medciation is locked has been
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This standard is not met as evidence by:
Per S-1 interview, on 09/07/21, during an unannounced visit conducted by San Gabriel Pomona Reg Center, the following was discovered: The small refrigerator that stores C-3’s insulin (for diabetes) was not locked. Per S-1 interview, the lock was hanging (unlocked) on the padlock latch.
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implemented. Proof of correction provided during today’s visit. POC CORRECTED.
Type A
09/22/2021
Section Cited
CCR
80075(k)(1)
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THIS A CONTINUATION OF 80075 (k)(1) Health Related Services: Per S-1 interview, staff were reminded to ensure the lock on the small refrigerator used to store medication is locked at all times.
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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: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4