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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602964
Report Date: 12/28/2023
Date Signed: 01/12/2024 09:17:52 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
12/20/2023 and conducted by Evaluator Ashley Calderon
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20231220125710
FACILITY NAME:PACIFIC HORIZONFACILITY NUMBER:
198602964
ADMINISTRATOR:KIM, MICHAELFACILITY TYPE:
735
ADDRESS:9115 UNION STTELEPHONE:
(562) 368-1479
CITY:PICO RIVERASTATE: CAZIP CODE:
90660
CAPACITY:6CENSUS: 4DATE:
12/28/2023
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Mylene Bumanlag/ AdministratorTIME COMPLETED:
04:35 PM
ALLEGATION(S):
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Dispensed Medication not properly documented.
Facility Staff mishandled P&I ledger.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ashley Calderon conducted an initial complaint visit in response to the allegations listed above. LPA met with Staff Juana Becker/ DSP and at 1:20pm Administrator Mylene Bumanlag joined to assist and LPA discussed the purpose of today's visit to both staff members.

During today's visit LPA collected and reviewed: resdient roster, staff roster will be emailed to LPA, Special Incident Reports (SIR) and Medication Records for Client #1 and Client #2 (C1 & C2), P&I ledger for C1, C2 and Client #3 (C3). LPA interviewed Administrator and Staff #1 (S1) and C1 and C3.

During today's visit DSP Juana Becker assisted LPA with medication review for C1 and C2 per interview with Administrator and S1 medication error occurred. Administrator assisted with medication explanation regarding incident that occurred once arriving to facility. LPA observed and reviewed P&I ledgers and monies was present and locked / stored for Client #1-Client #4 (C1-C4) for December 2023.

Continuation 9099-C...
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Ashley Calderon
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024
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-20231220125710
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: PACIFIC HORIZON
FACILITY NUMBER: 198602964
VISIT DATE: 12/28/2023
NARRATIVE
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Regarding the allegation: Dispensed Medication not properly documented. LPA alongside with Administrator and S1 reviewed records for September 2023 medication records (MARS) for C1 medication Lorazepham 1mg, as needed (PRN) was documented in the back of the MARS that C1 was given medication on Sept 10th 2023 at 7am, it was observed that facility did not properly document date given for Lorazepham PRN that was given at 2pm. Interview with S1 and Administrator informed LPA for C1 the way MARS documentation for 2pm medication for C1 PRN administration date was not clearly written using date format in the nurses notes. LPA reviewed SIR dated 9/25/23, stating medication error for C1 was observed and facility was notified by Quality Assurance Specialist from East Los Angeles Regional Center upon medication review of error. Medication review on MARS for C2 was observed to have documentation written once for date 5/09/23 for medication Acetaminophen 500mg and per interview S1 and Administrator informed LPA C2 was observed to have medication error. Administrator stated on 5/09/23, for C1 staff administered medication twice and staff documented once on MARS and not twice. Administrator informed LPA that medication training was provided to staff who administer medication.

Regarding the allegation: Facility Staff mishandled P&I ledger. LPA reviewed P&I's ledger and monies that were present at the facility for C1-C4 for the month of December 2023 and looked at past ledgers for ledger errors for clients who had ledger errors based on interviews with staff who informed LPA on the client's that were affected. Based on interview with S1 and Administrator there were documentation errors on ledgers for clients. Upon review for C1 and C2 past ledger LPA observed miscalculation for C1 for month of September 2023 and miscalculation for C2 for the month of August 2023. LPA observed Administrator documenting properly and adjusting C1 and C2 ledger and providing monies to client to make adjustment for error conducted.

Based on interviews, observation, and document review conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Tittle 22, are being cited, see 9099-D.

A copy of report, and appeal rights were provided to Mylene Bumanlag/ Administrator
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Ashley Calderon
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 28-AS-20231220125710
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: PACIFIC HORIZON
FACILITY NUMBER: 198602964
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/15/2024
Section Cited
CCR
80075(6)(C)
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80075 Health Related Services (6) If the client is unable to determine..own need for a presc. or nonpresc. PRN medication, & is unable to communicate..symptoms clearly, facility staff...be permitted to assist the client with self-admin. provided.
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Administrator will provide via email to LPA documentation for training for staff conducted for medication error.
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(C)The date and time the PRN medication was taken, the dosage taken, and the client's response, shall be documented and maintained in the client's facility record.

The requirement was not met as evidenced by:mediation documentation error for C1 for month Sept. 2023 for medication Lorazepham and C2 for month Aug. 2023 for medication Acetaminophen.
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Type B
01/15/2024
Section Cited
CCR
80026(h)
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80026 Safeguards for Cash Resources, Personal Property, and Valuables of Residents.
(h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care.
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Administrator will provide via email to LPA documentation of training for P&I ledger documentation and Admin. will continue to do new method of calculating monies in quiet area were clients are not distracting staff when calculating monies for clients.
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The requirement was not met as evidenced by:
C1 Aug date( 8/4/23) error balance miscalculation.
C2cJuly 2023 (7/21/23) error balance miscalculation.
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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: Ashley Calderon
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3