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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603505
Report Date: 05/03/2022
Date Signed: 05/03/2022 12:14:17 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
04/28/2022 and conducted by Evaluator Jewel Baptiste
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220428101158
FACILITY NAME:REM CALIFORNIA, LLC - GLENWOODFACILITY NUMBER:
198603505
ADMINISTRATOR:PARRA, DENISEFACILITY TYPE:
735
ADDRESS:2418 GLENWOOD PLACETELEPHONE:
(323) 249-8299
CITY:SOUTH GATESTATE: CAZIP CODE:
90280
CAPACITY:4CENSUS: 4DATE:
05/03/2022
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Care taker, Silvia RamirezTIME COMPLETED:
12:20 PM
ALLEGATION(S):
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Medication Error
INVESTIGATION FINDINGS:
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On 5/3/22 at 9:40 a.m., Licensing Program Analysts (LPA) Jewel Baptiste conducted an unannounced complaint investigation to the facility. Upon arrival, LPA met Caretaker Silvia Ramirez and LPA explained the reason for this visit is to discuss the above-mentioned allegation. Staff contacted administrator and LPA explained the reason for the visit.

Prior to this visit, LPA received a corrective action plan from Harbor Regional center citing medication error on 4/13/22.

During the visit, LPA toured the facility with S1, medication review and interviewed administrator (phone interview), Staff S1 and S2.

Report continued on 9099c
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Jewel Baptiste
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2022
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-20220428101158
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: REM CALIFORNIA, LLC - GLENWOOD
FACILITY NUMBER: 198603505
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/04/2022
Section Cited
CCR
80075(b)(5)(B)
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80075(b)(5)(B) Health-related services: Clients shall be assisted as needed with prescription and non-prescription medications...Once ordered by the physician, the medication is given according to the physician's instructions. This requirement was not met as evidenced by...
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The administrator stated that staff received medications training from the regional office on 4/22/22 and will provided additional training by facility nurse next week.The administrator provided a copy of the trainings completed on 4/22/22 and will provide a copy of the training log from facility to LPA by POC date
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Based on interviews, observation, and record reviews, the licensee did not ensure that C1's medications were given as prescribed on. LPA observed C2 Medication was not in bubble pack but Staff did not sign MAR. This poses an immediate health 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.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Jewel Baptiste
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20220428101158
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: REM CALIFORNIA, LLC - GLENWOOD
FACILITY NUMBER: 198603505
VISIT DATE: 05/03/2022
NARRATIVE
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The investigation reveals the following: Regarding "Medication error" it is alleged that the facility had a medication error on 4/13/22. Interviews with S1, S2 and administrator confirmed medication error occurred due to staff not following facility protocol. Administrator, S1 and S2 stated that training was given by Regional center on 4/22/22. Administrator stated another training is schedule by facility nurse to make sure they stay in compliance. LPA reviewed all residents’ medications and observed C2 medication (Docusate Sodium PM) was not in bubble pack but staff did not sign off on Medication Administration Record (MAR) as given.

Based on LPA’s observations, interviews, and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, is being cited on the attached LIC 9099D.

An exit interview was conducted, and a copy of this report was provided to the S2 along with the Appeals Rights.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Jewel Baptiste
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3