198603383-5-23-2024-28-AS-WSHO-D6ZUME-20240709154210

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603383
Report Date: 05/23/2024
Date Signed: 05/23/2024 04:16:14 PM

Unsubstantiated

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
03/04/2024 and conducted by Evaluator Nune Margaryan

COMPLAINT CONTROL NUMBER: 28-AS-20240304141910

FACILITY NAME:	TERRACES AT VIA VERDE-A MEMORY CARE COMMUNITY, THE		FACILITY NUMBER:	198603383
ADMINISTRATOR:	HIGGINS, DEBORAH		FACILITY TYPE:	740
ADDRESS:	1155 VIA VERDE		TELEPHONE:	(503) 443-1818
CITY:	SAN DIMAS	STATE: CA	ZIP CODE:	91773
CAPACITY:	60	CENSUS: 36	DATE:	05/23/2024
		UNANNOUNCED	TIME BEGAN:	03:57 PM
MET WITH:	Robert Jakini		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff mismanaged residents' medication

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Nune Margaryan conducted a subsequent unannounced complaint visit to deliver finding to the above mentioned allegation. LPA met with Robert Jakini and explained the reason for the visit.

The investigation consisted of the following: On 03/07/24 LPA Nune Margaryan obtained a copy of the resident and staff roster, copy of Med Staff Schedule, Medication Administration Records (Quick MAR) were reviewed. LPA also conducted interviews with Administrator and Staff #1 - Staff # 4 (S #1 - S #4).

Continue 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20240304141910

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: TERRACES AT VIA VERDE-A MEMORY CARE COMMUNITY, THE	FACILITY NUMBER: 198603383
	VISIT DATE: 05/23/2024

NARRATIVE

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The investigation revealed the following: in regard to the allegation " Staff mismanaged residents' medication.” It is alleged that medication administered without proper sign offs and medication being shared between patients / residents.

Interviewed Administrator and staff denied the allegation. They stated that staff did not shared medications between residents and all medications are administrated as prescribed and are noted electronically through a "Quick MAR" program. All residents’ medications are registered under the "Quick MAR" program. However, staff indicated they only have written MARs for new residents until their profile will be created in the system. All medications are administered on a consistent schedule. When residents refuse medication, Med Tech / LVNs document refusals, contact Resident's responsible party and contact the Prescribing Physician. Interviewed staff demonstrated to LPA how is worked "Quick MAR" program. LPA observed that residents medications are registered under the "Quick MAR" program. LPA also reviewed written MAR and observed medications are documented properly and given as prescribed. Administrator and staff indicated that each Med. Tech. / LVNs have their own login passwords. The information gathered does not corroborate the allegation noted above.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

An exit interview was conducted and a copy of this report was provided Robert Jakini.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

LIC9099 (FAS) - (06/04)

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