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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603472
Report Date: 08/01/2024
Date Signed: 08/01/2024 02:46:53 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
07/25/2024 and conducted by Evaluator Luis Mora
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240725101705
FACILITY NAME:TERN BAY HOMEFACILITY NUMBER:
198603472
ADMINISTRATOR:BOATNER, VERRETTAFACILITY TYPE:
735
ADDRESS:2213 TERN BAY LANETELEPHONE:
(424) 338-3054
CITY:LAKEWOODSTATE: CAZIP CODE:
90712
CAPACITY:3CENSUS: 2DATE:
08/01/2024
UNANNOUNCEDTIME BEGAN:
08:39 AM
MET WITH:Darcy Farais – Area DirectorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Resident is missing a medication
Staff did not report medication error to Community Care Licensing
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced initial complaint visit to determine the validity of the above-mentioned allegations. LPA met with Darcy Farais (Area Director) and explained the reason for the visit.

The investigation consisted of the following: LPA Mora interviewed Area Director, Staff 1 - Staff 3 (S1-S3), Client 1 - Client 2 (C1-C2), and C1's Regional Center Service Coordinator. LPA also reviewed C1's file.

The investigation revealed the following: regarding the allegation "resident is missing a medication", it is alleged that C1's 5pm Midodrine 5mg pill for 07/21/2024 was missing from the medication bubble pack. Interviews with staff revealed that the pill was reported missing by the LVN working that shift and no one knows what happened to that pill.

(Continued to LIC 9099-C)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
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 5
Control Number 28-AS-20240725101705
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: TERN BAY HOME
FACILITY NUMBER: 198603472
VISIT DATE: 08/01/2024
NARRATIVE
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C1 is non-verbal and was not able to provide information. Regional Center Service Coordinator was unaware of the 07/21/2024 missing pill and they received an incident report on 07/16/2024 providing information about medication documentation errors for C1 that occurred on the months of April and May 2024. At this point it is unknown what happened to C1's 07/21/2024 5pm Midodrine 5mg pill.

Regarding the allegation "staff did not report medication error to Community Care Licensing", it is alleged that this medication error was not reported to the Community Care Licensing Department (CCLD) because the previous administrator has instructed staff to not report to avoid citations. Per interviews this medication error was not reported to CCLD. LPA Mora did not see an incident report submitted to CCLD.

Based on LPA's interviews and records reviewed, the preponderance of evidence standard has been met, therefore the allegations are found SUBSTANTIATED. California Code of Regulations Title 22, Division 6, and Chapter 1 are being cited on the attached LIC 9099-D.

Exit interview held and a copy of the report and appeal rights was provided.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20240725101705
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: TERN BAY HOME
FACILITY NUMBER: 198603472
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/02/2024
Section Cited
CCR
80065(a)
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Personnel Requirements
(a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.

This requirement is not met by:
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Facility is to ensure that Title 22 Section 80065 regulations are met at all times. Additionally, an in-service training is to be conducted regarding medication and a training log with staff signature submitted to CCLD by 08/12/2024.
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Based on interviews and records review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. Facility staff failed to safeguard C1's medication.
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Facility has a scheduled in-service training for 08/09/2024 and requested for a due date of 08/12/2024.
Type B
08/09/2024
Section Cited
CCR
80061(b)(1)(E)
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Reporting Requirements
(b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event. (1) Events reported shall include the following: (E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.
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Facility is to ensure that Title 22 Section 80061 regulations are met at all times. Additionally, an in-service training is to be conducted regarding reporting requirements and a training log with staff signature submitted to CCLD by 08/12/2024. Facility will also submit an incident report to CCLD regarding the missing pill by 08/02/2024.
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Based on interviews and records review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. Facility did not submit an incident report regarding the missing pill to CCLD.
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Facility has a scheduled in-service training for 08/09/2024 and requested for a due date of 08/12/2024.
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: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
07/25/2024 and conducted by Evaluator Luis Mora
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240725101705

FACILITY NAME:TERN BAY HOMEFACILITY NUMBER:
198603472
ADMINISTRATOR:BOATNER, VERRETTAFACILITY TYPE:
735
ADDRESS:2213 TERN BAY LANETELEPHONE:
(424) 338-3054
CITY:LAKEWOODSTATE: CAZIP CODE:
90712
CAPACITY:3CENSUS: 2DATE:
08/01/2024
UNANNOUNCEDTIME BEGAN:
08:39 AM
MET WITH:Darcy Farais – Area DirectorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
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5
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9
Facility did not accommodate client's needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced initial complaint visit to determine the validity of the above-mentioned allegation. LPA met with Darcy Farais (Area Director) and explained the reason for the visit.

The investigation consisted of the following: LPA Mora interviewed Area Director, Staff 1 - Staff 3 (S1-S3), Client 1 - Client 2 (C1-C2), and C1's Regional Center Service Coordinator. LPA also reviewed C1's file.

The investigation revealed the following: regarding the allegation "facility did not accommodate client's needs", it is alleged that there is a doctor's order for C1 to have a hospital bed. Area Director stated that the facility requested an order from the doctor to be able to get hospital bed a few months ago, but they did it to make it easy for the staff to provide bedside assistance like rotating and chaging C1. They did receive a hospital bed, but it was not a good hospital bed and returned it back to the supplier. (Continued to LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20240725101705
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: TERN BAY HOME
FACILITY NUMBER: 198603472
VISIT DATE: 08/01/2024
NARRATIVE
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Interview with C1's regional center service coordinator revealed that C1 is not in need of a hospital bed per C1's Individual Program Plan (IPP). LPA Mora reviewed C1's file to see if a hospital bed was needed as part of C1's needs and care plan, but did not see anything.

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 allegations is unsubstantiated.

Exit interview held and a copy of the report was provided
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5