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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603556
Report Date: 04/30/2024
Date Signed: 04/30/2024 04:42:14 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
04/29/2024 and conducted by Evaluator Christine Wong
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240429154202
FACILITY NAME:NAVILLA VISTA RESIDENTIAL CAREFACILITY NUMBER:
198603556
ADMINISTRATOR:PASCASIO, GLORIEFACILITY TYPE:
735
ADDRESS:672 E. NAVILLA PLTELEPHONE:
(626) 241-4891
CITY:COVINASTATE: CAZIP CODE:
91723
CAPACITY:4CENSUS: 4DATE:
04/30/2024
UNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Gloria PascasioTIME COMPLETED:
04:50 PM
ALLEGATION(S):
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Injections being administered by unqualified staff.
Staff not keeping an accurate medication log.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Wong conducted an initial 10 days complaint to ascertain information pertaining to the above-mentioned allegation(s) and to establish the validity of the complaint. LPA met with Staff #1 Karla Carrenos (DSP) who allowed entry into the facility and was later met by Administrator Gloria Pascasio who assisted with the visit.

The investigation consisted of the following: On the above date, LPA interviewed administrator, three staff (S2-S4) and two clients (C1-C2) and attempted to interview Client#3 (C3) and reviewed C1's files and C2 and C3's P&I log book and receipts and all three clients' medication and Medication Administration Record (MARs).

Please see LIC9099C for continuation.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024
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
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
04/29/2024 and conducted by Evaluator Christine Wong
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240429154202

FACILITY NAME:NAVILLA VISTA RESIDENTIAL CAREFACILITY NUMBER:
198603556
ADMINISTRATOR:PASCASIO, GLORIEFACILITY TYPE:
735
ADDRESS:672 E. NAVILLA PLTELEPHONE:
(626) 241-4891
CITY:COVINASTATE: CAZIP CODE:
91723
CAPACITY:4CENSUS: 4DATE:
04/30/2024
UNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Gloria Pascasio TIME COMPLETED:
04:50 PM
ALLEGATION(S):
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9
Staff stole residents money.
INVESTIGATION FINDINGS:
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9
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12
13
Licensing Program Analyst (LPA) Wong conducted an initial 10 days complaint to ascertain information pertaining to the above-mentioned allegation(s) and to establish the validity of the complaint. LPA met with Staff #1 Karla Carrenos (DSP) who allowed entry into the facility and was later met by Administrator Gloria Pascasio who assisted with the visit.

The investigation consisted of the following: On the above date, LPA interviewed administrator, three staff (S2-S4) and two clients (C1-C2) and attempted to interview Client#3 (C3) and reviewed C1's files and C2 and C3's P&I log book and receipts and all three clients' medication and Medication Administration Record (MARs).

Please see LIC9099C for continuation.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20240429154202
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: NAVILLA VISTA RESIDENTIAL CARE
FACILITY NUMBER: 198603556
VISIT DATE: 04/30/2024
NARRATIVE
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The investigation revealed of the following: Allegation "Staff stole residents money." It's alleged that staff stole clients' money (C2-C3) for the past 2-3 months while doing the shopping for the clients and it's not adding up correctly what was spent. LPA interviewed clients and denied the allegation and stated no staff stole clients money. LPA interviewed staff and denied the allegation and stated no staff stole clients money. LPA also reviewed clients (C2-C3) P&I ledger and money and everything was accurate and updated. All the receipts are matching the spent down on the P&I.

Based on the interviews conducted with staff and clients and record reviewed, Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur; therefore the allegation is UNSUBSTANTIATED.

Exit Interview conducted and a copy of the report was provided to the administrator Gloria Pascasio.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20240429154202
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: NAVILLA VISTA RESIDENTIAL CARE
FACILITY NUMBER: 198603556
VISIT DATE: 04/30/2024
NARRATIVE
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The investigation revealed of the following: Allegation#1 "Injections being administered by unqualified staff." It's alleged that a facility staff (S1) is not certified to administer injection for C1." LPA interviewed C1 and confirmed S1 was the staff who administered the injection to C1. The administrator indicated S1 is no longer working in the facility since Sunday. C1 usually has a home health nurse funded by Regional Center who comes on every Friday to administer injection to C1 and staff would also bring C1 to mother's home and mother would administer the injection to C1 if needed. LPA reviewed S1's file and did not observe any document which indicated that S1 is a certified Licensed Vocational Nurse (LVN).

Allegation#2 "Staff not keeping an accurate medication log." It's alleged that staff would hide all PRN medications, stronger dosages in the garage or the facility van. LPA reviewed three clients' medication and two out of three medication are accurate and updated but LPA observed C1's PRN medication (Hydroxyzine HCL 25mg) which listed on the Medication Administration Record (MARs) but there's no medication in the facility.

Based on the record review and interviews conducted with staff and clients, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

Deficiency cited on the attached LIC 9099D. An exit interview was conducted, and a copy of this report was provided to the Administrator, Gloria Pascasio along with the Appeals Rights.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20240429154202
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: NAVILLA VISTA RESIDENTIAL CARE
FACILITY NUMBER: 198603556
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/01/2024
Section Cited
CCR
80075(b)(2)
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80075 Health Related Services (b)Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (2)Facility staff, except those authorized by law, shall not administer injections but staff designated by the licensee shall be authorized to assist clients with self-administration of injections as needed.

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Administrator will ensure facility staff except those authorized by law shall not administer injections and Administrator will send a plan for C1's upcoming injection schedule and whom will inject for C1 to LPA by POC due date.
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The requirement was not me as evidenced by record review, LPA reviewed S1's file who administer injection to C1 and does not have any LVN license file in S1's personnel file
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Type A
05/01/2024
Section Cited
CCR
80075(b)(5)(B)
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80075 Health Related Services (b)Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.(5)If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN ..... providing all of the following requirements are met: (B)Once ordered by the physician the medication is given according to the physician's directions.
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Administrator will schedule an in-service training on Medication Management for all facility staff in charge of medication administration and date provided to Licensing by POC due date.
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The requirement was not met as evidenced by record review, LPA reviewed C1's PRN medication (Hydroxyzine HCL 25mg) was not in the facility but it's on the list of MARs.
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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: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5