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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603525
Report Date: 04/15/2025
Date Signed: 04/15/2025 10:57:53 AM

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
01/07/2025 and conducted by Evaluator Noemi Galarza
COMPLAINT CONTROL NUMBER: 28-AS-20250107125448
FACILITY NAME:LAMBERT PLACE, THEFACILITY NUMBER:
198603525
ADMINISTRATOR:ALVAREZ, EDUARDOFACILITY TYPE:
737
ADDRESS:13304 LAMBERT RDTELEPHONE:
(909) 631-8521
CITY:WHITTIERSTATE: CAZIP CODE:
90602
CAPACITY:3CENSUS: DATE:
04/15/2025
UNANNOUNCEDTIME BEGAN:
09:37 AM
MET WITH:Derrez Coleman, RBT LeadTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff mismanaged resident medication.
Staff did not follow reporting requirements.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint investigation visit to conduct interviews, collect documents, and deliver findings on the above allegations. LPA discussed the purpose of the visit with RBT Lead Derrez Coleman.

The investigation consisted of: On 1/14/25, a tour of the facility, record review, and interviews with staff (S1 &S2) were conducted. Client records were requested and obtained, with the exception of client (C1's) May 2024 Medication Administration Record (MAR). As part of the investigation, the CCLD Regional Office received Eastern Los Angeles Regional Center Corrective Action Plan.

During today's visit, staff (S3-S5) were interviewed, client medications were reviewed and May 2024 MAR reports were obtained.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2025
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-20250107125448
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: LAMBERT PLACE, THE
FACILITY NUMBER: 198603525
VISIT DATE: 04/15/2025
NARRATIVE
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Allegation: Staff mismanaged resident medication. The complaint alleges that in May 2024 there was three medication errors pertaining to two clients. On May 1, 2024, client (C1) did not receive medication Clonazepam tablet due to "pharmacy not delivering medication on time". The second medication error occurred on May 13, 2024. C1's Polyethylene Glycol note on Medication Administration Record (MAR) states dose was missed because "pending medication from pharmacy". The third medication error occurred on May 17, 2024. Client (C2's) AM Haloperidol 5mg pill was still in the bubble pack at 2:50 PM. Per staff interviews, Administrator confirmed that in May 2024, two of C1's medications ran out because staff failed to place a pharmacy medication order before the medication supply was finished. A total of five (5) staff were interviewed. Staff interviews revealed that during the time of medication mismanagement licensee did not have a medication policy in place and there was no staff responsible for checking client medications to ensure they are ordered in a timely manner to ensure there is a 30-day supply of medications. Staff stated that since the medication errors, 15 minute checks are done after lead staff administer medications. Daily audits have been put in place during each shift to ensure there are no medication errors, and refills are now ordered liquid medication bottles are half filled. On 12/16/2024, the Regional Center issued a Corrective Action Plan (CAP) based on substantial inadequacies that posed the health and safety of clients in care. Therefore, the findings indicate there is corroborating evidence to support the allegation.

Allegation: Staff did not follow reporting requirements. It was reported that the medication errors listed in the above allegation pertaining to clients (C1 & C2) were not reported to Eastern Los Angeles Regional Center or Community Care Licensing because facility Administrator and staff were unaware that all medication errors, psychotropic or not, that are not administered to the individual warrant the submittal of an incident report. Administrator stated that when C1's medication ran out, a liaison staff from Regional Center was contacted and they informed Administrator that and incident report was not required. Other staff interviewed stated they did not know if Administrator reported the medication errors to Regional Center or Community Care Licensing, as it is the Administrator's responsibility to report incidents. Nevertheless, Administrator should reference California Code of Regulations and train all staff on requirements for special incident reporting. Based on record review and interviews, there is sufficient evidence to corroborate the allegation.

Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. Deficiencies are cited according to California Code of Regulations, Title 22. Refer to LIC 9099D.

Exit interview was conducted with Derrez Coleman and a copy of appeal rights and report was issued.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20250107125448
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: LAMBERT PLACE, THE
FACILITY NUMBER: 198603525
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/16/2025
Section Cited
CCR
80075(b)(5)(B)
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Health Related Services. Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.....Once ordered by the physician the medication is given according to the physician's directions.

This requirement was not met evidenced by:
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Administrator shall submit:
1. Written Plan of Correction
2. Proof of staff training
3. Copy of Medication Administration Policy/Procedures
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Based on record review and interviews, on May 1, 13, & 17, 2024, staff were not able to administered 3 medications to clients (C1 & C2) because staff did not place a pharmacy order and there was no supply of medications onsite. This posed an immediate health, safety, and personal rights risks to clients in care.
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Type B
04/22/2025
Section Cited
CCR
80061(b)(1)(E)
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Reporting Requirements. Events reported shall include the following: Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.
This requirement was not met by evidence of:
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Administrator shall submit a written plan of correction, proof of staff training, and copies of the incident reports pertaining to medication errors.
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Based on record review and interviews conducted, the findings indicate that staff failed to report to Regional Center and CCLD mismanagement of three (3) medications that occurred in May 2024 pertaining to C1 & C2. This posed a potential health, safety, and personal rights risk to clients 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: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3