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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603609
Report Date: 05/28/2025
Date Signed: 05/28/2025 03:18:28 PM

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
05/21/2025 and conducted by Evaluator Glenn Trueman
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250521100605
FACILITY NAME:HALIFAX HOUSEFACILITY NUMBER:
198603609
ADMINISTRATOR:MAGEE, WANDAFACILITY TYPE:
735
ADDRESS:4539 HALIFAX RD.TELEPHONE:
(626) 443-1313
CITY:EL MONTESTATE: CAZIP CODE:
91731
CAPACITY:4CENSUS: 4DATE:
05/28/2025
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Staff S1TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff mismanaged client's medication
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Glenn Trueman, made a visit to Halifax House.The purpose of today's visit is to investigate the allegation above.
On today's visit LPA met with Staff S1 and explained the reason for the visit.
File for Client C1 was reviewed and MAR Log for October 2024, Physician's Report , ID Sheet and IPP were submitted.
Medication was reviewed for Client C1.
LPA received a report from the SG/Pomona Regional Center dated October 28, 2024. The report states that on the morning of September 25, 2024 Client C1's Medication, Benztropine MES 0.5 TAB which is prescribed as 1 tablet by mouth twice a day was not administered.. The medication error was not identified by the Staff or by the Administrator prior to the evaluation nor was the incident documented in the MAR or Client Notes.
Interview was conducted telephonically with Administrator Wanda Magee at today's visit at 1:50 PM who confirmed that medication was not given in the morning for Client C1 and not documented. Stated that a





Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025
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-20250521100605
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: HALIFAX HOUSE
FACILITY NUMBER: 198603609
VISIT DATE: 05/28/2025
NARRATIVE
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Corrective Action Plan (CAP) was given and staff were trained regarding administering and documenting medication. Said it was overlooked by Staff and was a one time error.

Based on LPA's observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22) cited on the attached 9099 D.

Exit interview conducted.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20250521100605
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: HALIFAX HOUSE
FACILITY NUMBER: 198603609
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
05/29/2025
Section Cited
CCR
87465(a)(A)
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Incidental Medical and Dental
A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
Medications usually prescribed for self-administration which have been authorized by the person's physician.


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Administrator is to provide in-service training to all staff on appropriate medication dispensing procedures and email the materials and list of attendees to LPA by the POC due date.
Proof of training submitted to LPA.
Deficiency cleared.

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This requirement was not met as evidenced by:
Based on documentation and interview licensee failed to provide assistance with self administered medication with Client C 1 missing morning dose of medication which posed an Immediate Health and Safety Risk to resident 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: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3