198603567-8-13-2024-28-AS-RORN-D8RLNU-20240903085456

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603567
Report Date: 08/13/2024
Date Signed: 08/13/2024 01:53:43 PM

Unsubstantiated

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
08/07/2024 and conducted by Evaluator Tena Herrera

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240807093544

FACILITY NAME:	CLAREMONT HACIENDA, THE		FACILITY NUMBER:	198603567
ADMINISTRATOR:	CLARK, DONELL		FACILITY TYPE:	740
ADDRESS:	501 SOUTH COLLEGE AVENUE		TELEPHONE:	(909) 626-0117
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY:	68	CENSUS: 48	DATE:	08/13/2024
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Cassandra Crawley - Wellness Director		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff administered unprescribed medications to resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint investigation to investigate the above allegation. LPA met with Wellness Director Cassandra Crawley and explained the purpose of the visit.

The investigation consisted of the following:
LPA obtained copies for the resident and staff rosters, copies Medication Administration Records (MARs) for Resident #1&2 (R1 & R2), Medical Record for R2, toured the medication room, reviewed medications, and interviewed 3 Staff and 5 Residents.

(Continued on LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20240807093544

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: CLAREMONT HACIENDA, THE	FACILITY NUMBER: 198603567
	VISIT DATE: 08/13/2024

NARRATIVE

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The investigation revealed the following:
Allegation: Staff administered unprescribed medications to resident.
It is alleged that R1 was given medication that belongs to R1 and that R2 was given insulin when that medication is not prescribed to them. LPA reviewed MAR's for both R1 and R2 and observed that R2 is prescribed insulin by doctor, medical records also documented the insulin as prescribed medication by R2's doctor. During review of R1's medical records it was observed that they did not have Benadryl as a medication listed on their MAR, however, interview with Wellness Director Cassandra revealed that she recalls this conversation with staff and the medication the complaint is referring to is for a PRN medication that she instructed staff to administer to R1 when R1 is feeling agitation or aggression. On this particular date Cassandra stated that R1 was showing symptoms of agitation as they were exit seeking and had to be redirected. LPA interviewed 2 additional staff and both stated that they have not administered unprescribed medication to residents. LPA interviewed 5 residents and 5 out of 5 residents stated that they have not been administered medication that is not prescribed to them.

Based on statements and interviews conducted with staff and residents, review of resident files and medication, there was not enough supportive evidence to concur with the reported allegation.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview held, and a copy of this report was provided.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

LIC9099 (FAS) - (06/04)

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