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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602931
Report Date: 11/29/2021
Date Signed: 11/29/2021 11:21:57 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
11/22/2021 and conducted by Evaluator Kruz Long
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20211122122504
FACILITY NAME:JOSHUA TREE HOMEFACILITY NUMBER:
198602931
ADMINISTRATOR:JASMIN TOMINESFACILITY TYPE:
735
ADDRESS:18207 VILLA CLARA STREETTELEPHONE:
(626) 295-2197
CITY:ROWLAND HEIGHTSSTATE: CAZIP CODE:
91748
CAPACITY:6CENSUS: 6DATE:
11/29/2021
UNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Alvin Capanzana (Caregiver)TIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff mishandled a client's medication while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kruz Long conducted an unannounced complaint visit to the facility. Upon arrival, LPA met with Alvin Capanzana (Caregiver) and explained the purpose of the visit.

During today's visit, LPA obtained a copy of the Staff Schedule, Client roster, MAR (Nov. 2021) for Client #1 and reviewed medications for Client #1.

In regards to the allegation: Staff mishandled a client's medication while in care. LPA interviewed Staff #1 who stated that there was a medication error for Client #1. A review of the medication records indicate that 11/16/21 medications (Quetiapine Fumarate 200MG 5pm, Risperidone 1MG 5 pm) for Client #1 was not dispensed and remained in the bubble pack.

Continue to LIC9099C....
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Kruz Long
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2021
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-20211122122504
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: JOSHUA TREE HOME
FACILITY NUMBER: 198602931
VISIT DATE: 11/29/2021
NARRATIVE
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Based on LPA's interview and record review, investigation revealed that 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 on the attached LIC 9099D.

Exit interview conducted with Alvin Capanzana and a copy of this report and appeal rights provided.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Kruz Long
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20211122122504
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: JOSHUA TREE HOME
FACILITY NUMBER: 198602931
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/30/2021
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 evidenced by:
A review of the medication records indicate that 11/16/21 medications (Quetiapine Fumarate 200MG 5pm,
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Licensee shall provided additional training to all Staff pertaining to Section 80075(b) and provided proof of training to the department by 12/03/21.
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Risperidone 1MG 5 pm) for Client #1 was not dispensed and remained in the bubble pack.
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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.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Kruz Long
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3