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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603251
Report Date: 04/22/2022
Date Signed: 04/22/2022 02:18:34 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
05/26/2020 and conducted by Evaluator Kruz Long
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20200526155837
FACILITY NAME:VB CARE HOMESFACILITY NUMBER:
198603251
ADMINISTRATOR:BEVINAHALLI SURESHFACILITY TYPE:
735
ADDRESS:18412 DEL BONITATELEPHONE:
(714) 393-6361
CITY:ROWLAND HEIGHTSSTATE: CAZIP CODE:
91748
CAPACITY:6CENSUS: 6DATE:
04/22/2022
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Daisy Carrillo (Caregiver)TIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility staff did not dispense medication as prescribed.
Facility staff failed to properly dispose of discontinued medication.
INVESTIGATION FINDINGS:
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***This report supersedes LIC9099 dated 10/15/21.***

Licensing Program Analyst (LPA) Kruz Long conducted an unannounced complaint visit to the facility. Upon arrival, LPA met with Daisy Carrillo (Caregiver) and explained the purpose of the visit.

During a telephonic visit on 06/02/20, LPA called and interviewed Staff #1. Staff #1 was advised to fax copies of the medication logs (MAR) to the department.

During today's visit, LPA obtained a copy of the Staff/Client roster.

In regards to the allegation: Facility staff did not dispense medication as prescribed. LPA's review of medication records revealed that on 05/10/20, medications for Client #1 was not dispensed as prescribed. Interview with Staff #1 indicate medications for Client #1 was not properly dispensed. Witness also observed Client #1's medications not dispensed as prescribed.
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: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022
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-20200526155837
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: VB CARE HOMES
FACILITY NUMBER: 198603251
VISIT DATE: 04/22/2022
NARRATIVE
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***This report supersedes LIC9099C dated 10/15/21.***

In regards to the allegation: Facility staff failed to properly dispose of discontinued medication. Witness observed discontinued medications for Client #2 and #3 still in their medication basket. Interview with Staff #1 indicate that discontinued medication was not disposed due to the COVID-19 pandemic and pharmacy refused to pick up discontinued medications.

Based on LPA's file review, interview and Witness observations, the investigation revealed that 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 and Chapter 1 are being cited on the attached LIC 9099D.

Exit interview conducted with Daisy Carrillo (Caregiver) 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: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20200526155837
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: VB CARE HOMES
FACILITY NUMBER: 198603251
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/23/2022
Section Cited
CCR
80075(b)(5)(C)
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80075(b)(5)(C) (C) A record of each dose is maintained in the client's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the client's response.
This requirement is not met evidenced by: Medication records review and interview revealed that on 05/10/20, medications for
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Licensee shall provide additional medication administration assistance training to all Staff and provide proof to the department by the POC date.
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Client #1 was not dispensed as prescribed. Witness also observed Client #1's medications not dispensed as prescribed.
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Type B
05/06/2022
Section Cited
CCR
80075(l)(1)(D)
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80075(l)(1)(D) Health Related Services
(l) (1) Both shall sign a record, to be retained
for at least one year, which lists the following: (D) The date of destruction. This requirement is not met as evidenced by: Witness observed discontinued medications for Client #2 and #3 still in their medication basket.
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Licensee shall review Title 22, Section 80075(l)(1)(D) and provide a signed statement indicating this section is understood along with a record of the medications destruction log for discontinued medications (May 2020).
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Interview with Staff #1 indicate that discontinued medication was not disposed due to the COVID-19 pandemic and pharmacy refused to pick up discontinued medications.
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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: 04/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3