<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603504
Report Date: 04/25/2024
Date Signed: 04/25/2024 03:09:02 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
11/09/2023 and conducted by Evaluator Noemi Galarza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20231109122933
FACILITY NAME:LA POSADAFACILITY NUMBER:
198603504
ADMINISTRATOR:DIANA BAUTISTAFACILITY TYPE:
740
ADDRESS:8120 PAINTER AVETELEPHONE:
(562) 945-2651
CITY:WHITTIERSTATE: CAZIP CODE:
90602
CAPACITY:114CENSUS: 90DATE:
04/25/2024
UNANNOUNCEDTIME BEGAN:
10:07 AM
MET WITH:Diana Bautista, AdministratorTIME COMPLETED:
03:10 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not refill residents medication timely.
Staff gave resident another residents medication.
Facility staff falsified documents.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit to investigate the above allegations and deliver findings.The purpose of the visit was discussed with Administrator Diana Bautista.

The investigation consisted of the following: On 11/6/23, the physical plant was toured and R1's medications were reviewed. There was a COVID-19 outbreak in the building and all communal dining and activities were postponed at the time of the visit. Residents were quarantined and interviewed in their rooms. LPA interviewed residents (R1- R6) and Staff (S1- S6). Resident (R1's) file documents [Identification and Emergency Information/Face Sheet, Medication Administration Records [Sep. 2023 - Nov. 2023], Physician's Reports, Preplacement Appraisal, Resident Appraisal, ALW Individual Service Plan, Narrative charting notes, Incident Reports, admission agreement, resident roster, and LIC 500 Personnel Report. During today's visit, R1's medications were reviewed, record review was conducted, resident (R1) was interviewed, and common areas were inspected. Rosters were obtained as well.

*Narrative continues next page.
Substantiated
Estimated Days of Completion: 90
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
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-20231109122933
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: LA POSADA
FACILITY NUMBER: 198603504
VISIT DATE: 04/25/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Allegation: Staff did not refill residents medication timely. It is alleged that on October 5, 2023 at approximately 9:30 PM, resident (R1's) blood sugar level was 534 because facility staff failed to reorder insulin medication. According to information obtained PM shift facility staff did not dispense the insulin medication before the resident's dinner meal, which resulted in a dangerous blood sugar level. A total of seven (7) staff were interviewed, which included the staff (S1) that was on shift on 10/5/23. Staff (S1) stated that R1's blood sugar was checked in the early afternoon hours and "it was high". Staff (S1) stated they went to the medication room and there was no insulin left, and the insulin order indicated "zero refills". Therefore, S1 called the pharmacy and they were not able to refill the medication without a current physician order. According to S1, they faxed R1's MD, but did not receive a response. Staff (S1) stated that they spoke to R1 and informed the resident that they could wait for the emergency insulin delivery and/or offered to transport the resident to the hospital. Staff acknowledged they waited "4 hours" to notify the Wellness Nurse and family because they were the only med-tech on duty in the PM shift. All staff interviewed acknowledged that the med-tech staff failed to order insulin medication when it was observed the resident was running low. According to facility protocol, med-techs are supposed to contact the doctor when medication refills are needed. Wellness Director acknowledged that med-tech staff knew the day before R1 ran out of insulin that a new order would be needed. It was stated that the AM med-tech staff should have ordered the insulin, but none of the staff documented the medications needed to be ordered. Family was contacted and they transported R1 to the hospital in order for the resident to be evaluated and so they could receive insulin medication. Facility staff did not call 911 emergency. The findings indicate med-tech staff failed to order R1's insulin medication after observing the insulin supply was running low. There is sufficient evidence to corroborate the allegation.

Allegation: Staff gave resident another residents medication. It is alleged that on Sunday, October 29, 2023, med-tech staff (S2) dispensed four (4) wrong medications to resident (R1). According to information obtained, R1 was dispensed their evening medications, and also dispensed another resident's medications. Staff interviews revealed that staff (S1) left another resident's medications in R1's room, and asked other caregivers to check in on R1 and to get the other resident's medications that were left in the room. When staff (S2) went to the room, the other resident's medications were there, and staff assumed they belonged to R1. Therefore, S2 asked the resident to take their medications. According to interviews, staff (S2) misunderstood the instructions given by S1. Per file review, R1 has a diagnosis of early on-set Dementia. All staff interviewed acknowledged the medication error. Per facility protocol, staff cannot leave medications unlocked. Family was notified of medication error and transported the resident to the local hospital. Staff did not call 911 emergency. Therefore, staff negligence is corroborated.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20231109122933
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: LA POSADA
FACILITY NUMBER: 198603504
VISIT DATE: 04/25/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Allegation: Facility staff falsified documents. It is alleged that the incident report furnished upon request of R1's authorized representative pertaining to the October 5, 2023, in which med-tech staff failed to order and obtain insulin medication for R1 omitted the fact that insulin medication was not dispensed because the facility failed to refill and obtain a new physician order for the medication. LPA obtained a copy of the 2 incident reports provided to R1's authorized representative and compared it to what was submitted by staff to the Department of Social Services Community Care Licensing Division (CCLD) Regional Office. CCLD received a handwritten incident report completed by staff (S1), that stated that R1 wanted to be sent out to the hospital due to high blood sugar level readings, is waiting for insulin refill medication, and that paramedics were called and resident was transported to PIH Whittier Hospital. Staff (S1) stated that they called the paramedics for another resident and mistakenly mixed up the incidents. Med-techs, caregivers, and Wellness Director are in charge of filling out incident reports, which are then submitted to CCLD. In this case, the Wellness Director faxed the handwritten incident report that had incorrect information. A 2nd incident report was created and typed, and then provided to R1's authorized representative after family brought the false statements noted on the incident report to facility staff. However, the 2nd incident report was never faxed to CCLD. Therefore, there is sufficient evidence to corroborate that staff (S1) falsified documents.

Based on interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to Title 22. See LIC 9099D.

Exit interview was conducted with Administrator Diana Bautista. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20231109122933
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: LA POSADA
FACILITY NUMBER: 198603504
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/25/2024
Section Cited
CCR
87465(c)(2)
1
2
3
4
5
6
7
Incidental Medical and Dental Care. If the resident's physician has stated in writing that the resident is unable to determine his/her own need ........ facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: Once ordered by the physician the medication is given according to the physician's directions.

1
2
3
4
5
6
7
Administrator submitted proof of staff in-service training "CCLD Medication Guide" that was conducted on 12/6/2023 by former Wellness Director.
Administrator agreed to ensure that medication administration procedures are being evaluated routinely, especially when new med-tech staff are hired.
8
9
10
11
12
13
14
Based on records review and interviews, med-tech staff failed to order R1's insulin medication and on 10/5/23 the resident ran out of insulin resulting in dangerously elevated blood sugar levels; which posed an immediate health and safety hazard to the resident.
8
9
10
11
12
13
14
Licensee shall provide medication admininstration in-service training to all staff that dispense medications. This training shall be provided by pharmacy and/or registered nurse. Submit proof of training by POC due
Type A
05/02/2024
Section Cited
CCR
87411(d)(4)
1
2
3
4
5
6
7
Personnel Requirements - General
(d) All personnel shall be given on the job training or have related experience in the job assigned to them.... (4) Knowledge required to safely assist with prescribed medications which are self-administered. This requirement was not met evidenced by:
1
2
3
4
5
6
7
Administrator shall ensure that all staff are trained in job responsibilities,facility procedures, and all med-techs are adhering to company procedures.
Administrator provided in-service training that was conducted on 12/6/23. However, new med-tech staff have been onboarded. Therefore, new staff in-service training shall be submitted by POC due date.
8
9
10
11
12
13
14
Based on interviews and record review, on 10/29/23 med-tech left another resident's medications in R1's room and asked the resident to take the medications, which posed an immediatel health and safety risk to persons in care.
8
9
10
11
12
13
14
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) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20231109122933
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: LA POSADA
FACILITY NUMBER: 198603504
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/02/2024
Section Cited
CCR
87207
1
2
3
4
5
6
7
False Claims. No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement was not met evidenced by:
1
2
3
4
5
6
7
Administrator agreed to conduct staff in-service training on emergency call protocols, and incident report writing and oversight.

Submit proof of staff training.
8
9
10
11
12
13
14
Based on record review, the findings indicate that on 10/10/23, staff faxed to CCLD an incident report that contained falsified information and omitted details of R1's incident (10/5/23), in which staff did not refill in time R1's insulin. The report stated that paramedics were called, but they were not. This poses a potential health and safety risk to persons.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5