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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603638
Report Date: 10/04/2024
Date Signed: 10/04/2024 11:21:51 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
09/27/2024 and conducted by Evaluator Erik Zaragoza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240927154938
FACILITY NAME:MERCEDES DIAZ HOMES, INC. - JANINE HOMEFACILITY NUMBER:
198603638
ADMINISTRATOR:HERNANDEZ, ALEJANDROFACILITY TYPE:
735
ADDRESS:14858 JANINE DRTELEPHONE:
(562) 945-4576
CITY:WHITTIERSTATE: CAZIP CODE:
90603
CAPACITY:4CENSUS: 4DATE:
10/04/2024
UNANNOUNCEDTIME BEGAN:
08:46 AM
MET WITH:Brenda Venegas - AdministratorTIME COMPLETED:
11:37 AM
ALLEGATION(S):
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Medication Error
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Erik Zaragoza conducted an initial complaint visit to address the allegation listed above. LPA met with Brenda Venegas, administrator for the facility, and explained the purpose of the visit.

The investigation consisted of the following: During the visit, LPA interviewed Clients #2 - 4 (C2 - C4), Staff #1 - 4 (S1 - S4), obtained obies of the staff and client roster, and also reviewed the Medication Administration Records (MARs) along with the medications for Client #1 (C1) - C4. LPA attempted to interview Client #1, however LPA was not able to interview them because they are currently hospitalized. LPA also reviewed a Corrective Action Plan (CAP) received from the East Los Angeles Regional Center (ELARC) dated on 9/4/2024.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2024
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 3
Control Number 28-AS-20240927154938
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: MERCEDES DIAZ HOMES, INC. - JANINE HOME
FACILITY NUMBER: 198603638
VISIT DATE: 10/04/2024
NARRATIVE
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The investigation revealed the following: In regards to the allegation that there was a "Medication Error," it is alleged that on 2/22/2024 the medications for C1 were reviewed, and it was discovered that their medications were still in the bubble pack for the date of 2/21/2024, and the MARs was incorrectly marked indicating that the medication was provided to C1. During interviews with the clients, zero (0) out of four (4) corroborated the allegations that they have experienced any medications errors while living at the facility. LPA attempted to interview C1 regarding the allegation, however they are currently hospitalized. During interviews with the staff, two (2) out of four (4) corroborated that there was a medication error that occurred on this date. One staff interviewed stated that it was discovered on this date the evening medications were mistakenly not provided to C1, and that training was subsequently conducted in order to ensure that staff understand how to properly distribute medications to the clients. Another staff interviewed confirmed that training was conducted in response to the incident to ensure that it does not occur again. During record review of the CAP from ELARC, it explains how medications signed off on the MARs as if it were distributed however was still found in the bubble pack, and details the retraining that will be conducted amongst the staff in response to the incident.

Based on LPA interviews conducted with the clients and staff, the preponderance of evidence standard has been met for the above allegations, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations Title 22, Division 6, Chapter 1 is being cited on the attached LIC9099D.

Exit interview held administrator Brenda Venegas. Exit interview was held and a copy of the report along with the appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20240927154938
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: MERCEDES DIAZ HOMES, INC. - JANINE HOME
FACILITY NUMBER: 198603638
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/05/2024
Section Cited
CCR
80075(b)
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(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This regulations is not met as evidenced by:
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Administrator is to ensure that medications are properly distributed to clients and documented appropriately at all times. Administrator is to submit the training topics and materials from the medication retraining, along with a list of the staff who attended this training to the LPA by the POC due date.
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Based on interview and record review, LPA determined that medication was not administered to C1 on 2/21/2024, which posed an immediate health and safety risk to clients 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: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3