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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603383
Report Date: 03/05/2024
Date Signed: 03/05/2024 03:47:20 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
02/28/2024 and conducted by Evaluator Jewel Baptiste
COMPLAINT CONTROL NUMBER: 28-AS-20240228132910
FACILITY NAME:TERRACES AT VIA VERDE-A MEMORY CARE COMMUNITY, THEFACILITY NUMBER:
198603383
ADMINISTRATOR:HIGGINS, DEBORAHFACILITY TYPE:
740
ADDRESS:1155 VIA VERDETELEPHONE:
(503) 443-1818
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY:60CENSUS: 36DATE:
03/05/2024
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Executive Director Robert JakiniTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Unqualified staff are administering insulin.
INVESTIGATION FINDINGS:
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On 3/05/24 at 9:10 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced complaint visit to the facility. Upon arrival LPA met with the Executive Director Robert Jakini and explained the reason for the visit.

During the visit LPA toured the facility with Staff #1 and obtained the resident roster and staff roster. LPA also conducted file review for a former resident (R1) and obtained the following documents: Physicians report, centrally stored medication and destruction record dated 5/04/2020 and 9/30/2021, and Medication administration record that included discontinue request. LPA conducted file review for former staff and obtained the following documents: Staff #4 personnel record, signed SOC 341, and training. Staff #5 copy of Registered Nurse PN license. Staff# 6 through Staff #7 Vocational nursing details. LPA conducted file review for current staff and obtained the following documents: Staff #1 copy of Vocational nursing details. Staff #2’s personnel record, and trainings. LPA also interviewed the executive director and a total of 3 staff who shall be referred to as S1 through S3. LPA interviewed a total of 6 residents who shall be referred to as R2 through R7. (Report continued on 9099c)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024
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-20240228132910
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: 03/05/2024
NARRATIVE
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The investigation reveals the following: Regarding " Unqualified staff are administering insulin”. It is alleged that med techs are administering insulin injections to residents. LPA conducted file review and interviews and observed the following. Based on the interviews there was one (1) resident (R1) who has since passed away that needed insulin injections. LPA observed that R1 received Novolog injections subcutaneously for the month of September in 2023. The injections were administered by seven (7) different staff members during the month of September. LPA confirmed 2 out of the 7 staff was med techs that did not have the required licensed to administer insulin injections.

Based on LPA observation, interviews and file review, the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulation, Title 22 are being cited on the attached LIC9099D.



Exit Interview Conducted with Executive Director/ Appeal Rights Provided / A Copy of the Report Issued.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20240228132910
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/05/2024
Section Cited
HSC
1569.69
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1569.69 of the Health and Safety Code. It requires direct care staff in RCFEs, excluding licensed medical professionals, to meet specified training requirements, including passing an examination, in order to be able to assist residents with the self-administration of medications. It does not authorize unlicensed personnel to directly administer medications.

This requirement was not met as evidence by:
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The licensee shall conduct in-service training regarding medications administration and the role of med techs. The In-service training is due to LPA by POC due date.
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Based on observation, interview and record review, the licensee did not comply with the section cited above in that two (2) Staff administered insulin to resident #1 without a license to administer medications, which poses/posed a potential health, safety or personal rights risk to persons in care.
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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.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3