198603567-1-19-2023-28-AS-RORN-CNLS2W-20230131123013

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603567
Report Date: 01/19/2023
Date Signed: 01/19/2023 05:15:05 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
01/12/2023 and conducted by Evaluator Luis Mora

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230112135440

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: 47	DATE:	01/19/2023
		UNANNOUNCED	TIME BEGAN:	02:09 PM
MET WITH:	Verity Carda - Licensed Vocational Nurse		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff did not properly store medications.

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Luis Mora conducted an unannounced complaint visit to determine the validity of the above-mentioned allegations. LPA met with Verity Carda (Licensed Vocational Nurse) and explained the reason for the visit.

The investigation consisted of the following: On the morning of 01/19/2023, LPA obtained copies of the resident and staff rosters, interviewed Executive Director, and toured the medication room. LPA requested December 2022 MARs for all 47 residents. On the afternoon of 01/19/2023, LPA obtained copies of December 2022 MARs for all 47 residents, identified all the residents that were prescribed Norco in the month of December, and inspected these residents medication to determine if facility has their Norco medication in stock. LPA obtained copies of Resident 1 (R1) Identification and Emergency Information sheet, Uniform Statutory Form Power of Attorney, and January 2023 MARs. LPA also interviewed the facility's Licensed Vocational Nurse.
(CONTINUED TO LIC 9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023

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-20230112135440

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: 01/19/2023

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

The investigation revealed the following: regarding the allegation "facility staff did not properly store medications", it is alleged that a card of narcotics containing 100 Norco pills went missing from the facility the week of 12/19/22-12/23/22. Executive Director and staff denied the allegation. LPA Mora and Facility's Licensed Vocational Nurse (LVN) reviewed all 47 residents' medications to identify all the residents that were prescribed Norco also known as Hydrocodone-Acetaminophen in the month of December 2022. A total of 7 residents were identified. LPA reviewed these 7 residents medication to determine if the facility has their Hydrocodone-Acetaminophen medication in stock. At the time of the visit, the Hydrocodone-Acetaminophen medication RX # 6398657 for Resident 1 (R1) was not in the medication drawer. R1's December 2022 and January 2023 Medication Administration for Residents (MARs) has the Hydrocodone-Acetaminophen medication RX # 6398657 listed as a PRN. The LVN contacted the Executive Director and Associate Executive Director and was told that this medication was placed in the locked drawer where they keep the extra narcotic medication. R1's relative (Power of Attorney) asked the facility to not give R1 this medication anymore because it causes R1 hallucinations. However, R1's Uniform Statutory Form Power of Attorney states on the top the following: "This document does not authorize anyone to make medical and other health-care decisions for you". Furthermore, at the time of the visit the facility was unable to provide a discontinued order from the physician. The only ones with the key to that drawer are Executive Director and Associate Executive Director which were unable to come to the facility, therefore LPA was unable to confirm that they do have that medication in there.

Based on LPA's interviews and records reviewed, the preponderance of evidence standard has been met, therefore the allegation is found SUBSTANTIATED. California Code of Regulations Title 22, Division 6, Chapter 8 are being cited on the attached LIC 9099D.

Exit interview held and a copy of the report and appeal rights was provided.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20230112135440

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/19/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/20/2023 Section Cited CCR 87465(c)(1)(2)(3)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (c)If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident.......	1 2 3 4 5 6 7	Facility is to ensure that Title 22 Section 87465 regulations are met at all times. Additionally, facility will refill the PRN medication and have it available on the facility premises as required. Proof of the refill to be sumitted to CCLD by 01/20/2023.
	8 9 10 11 12 13 14	This requirement is not met as evidence by: Based on interviews and observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. R1's was missing the Hydrocodone-Acetaminophen medication RX # 6398657.	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: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3