198603550-11-28-2023-28-AS-LHIS-CY7JWR-20231204062506

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603550
Report Date: 11/28/2023
Date Signed: 11/28/2023 10:54:03 AM

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
09/20/2023 and conducted by Evaluator Alberto Lopez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230920090825

FACILITY NAME:	WEST PARK SENIOR LIVING		FACILITY NUMBER:	198603550
ADMINISTRATOR:	IRBY, LORI		FACILITY TYPE:	740
ADDRESS:	801 CYPRESS WAY		TELEPHONE:	(626) 339-5426
CITY:	SAN DIMAS	STATE: CA	ZIP CODE:	91773
CAPACITY:	200	CENSUS: 118	DATE:	11/28/2023
		UNANNOUNCED	TIME BEGAN:	10:01 AM
MET WITH:	Crystene Char, Administrator		TIME COMPLETED:	10:59 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff mismanages resident's medication.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Alberto Lopez made a subsequent unannounced visit to the facility and was greeted by Crystene Char, Administrator explained the reason for the visit.

During previous visit LPA interviewed 4 staff (S#1- S#4)Staff Ana Contreras, Katelyn Maloof, Jenny Ceballos, Crystene Char via phone, and 13 residents (R#1-R#13). LPA reviewed R1 file and obtained copies of pertinent medical information. LPA also interviewed W1 and W2.
The investigation revealed.

(Continued on 9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 11/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023

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-20230920090825

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: WEST PARK SENIOR LIVING	FACILITY NUMBER: 198603550
	VISIT DATE: 11/28/2023

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 mismanages resident's medication. It is alleged that the facility failed to administer medications according to doctor’s orders.
On 09/13/2023 R1 stated her blood pressure was high and asked Med-Tech for additional ½ dose of Hydralazine as her doctor had ordered back on 12/29/2022. Facility staff refused to give it to R1 telling her that they required a doctor’s order and could not locate any current doctor’s order that allowed facility to provide an extra ½ a tablet. On new doctor’s orders dated 05/16/2023 provided to facility it only included for Hydarlazine to be provided 3 x per day without the additional ½ tablet PRN and facility was acting based on that order. However, on the actual medication for Hydarlazine bottle filled on 7/23/2023, The orders are for 3 tablets per day and additional ½ tablet if SPB is over 150. The doctor’s order’s and label on the bottle must be identical and it was not.

Based on LPA observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. See 9099D for details.

Exit interview conducted with Crystene Char, Administrator, a copy of this report is being provided and Appeal Rights were given.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 11/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20230920090825

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: WEST PARK SENIOR LIVING	FACILITY NUMBER: 198603550
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/28/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/19/2023 Section Cited CCR 87465(e)(2)	1 2 3 4 5 6 7	87465 (e)(2) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. (2) The exact dosage	1 2 3 4 5 6 7	Administrator will write a letter stating how this will be addressed by facility and provide in service to all Medication Technicians on save medication handling.
	8 9 10 11 12 13 14	The requirement is not met as evidenced by: Doctor’s order dated 5/16/23 for Hydralazine dosage does not match the label dosage on the bottle dispensed on 07/23/23. The doctor’s order is for 1 tablet by mouth 3 times per day and label reads: Take 1 tablet by mouth 3 times per day. Ok to take extra one-half tablet if SHIP is above 150. Both the doctor’s order and the label should mirror each other. This posed/poses a health and safety hazard to persons in care.	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 Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 11/28/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3