210102866-9-13-2022-21-AS-BMOS-CJ9UC7-20220914152728

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 210102866
Report Date: 09/12/2022
Date Signed: 09/13/2022 10:12:25 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/11/2022 and conducted by Evaluator Carla Fernandes-Goes

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20220811091318

FACILITY NAME:	REDWOODS, THE		FACILITY NUMBER:	210102866
ADMINISTRATOR:	CATHERINE SCOTT		FACILITY TYPE:	740
ADDRESS:	40 CAMINO ALTO		TELEPHONE:	(415) 383-2741
CITY:	MILL VALLEY	STATE: CA	ZIP CODE:	94941
CAPACITY:	150	CENSUS: 120	DATE:	09/12/2022
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Catherine Scott - Administrator		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility did not dispense medication as prescribed by doctor.

INVESTIGATION FINDINGS:

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

kThe Department conducted a complaint investigation regarding the allegation listed above. Licensing Program Analyst Fernandes-Goes arrived unannounced for the purpose of closing the investigation and met with Catherine Scott - Administrator.

On 8/17/2022, LPA Fernandes-Goes toured the facility with Thanh Nguyen - LVN AL; conducted interviews; acquired documentation; and made observations of the facility. During interviews with complainant and staff on 8/16 and 8/17/2022 and documentation reviewed on 8/17/2022, Department learned that facility residents R2, R3, R4 have had medication that were not dispensed as prescribed by doctor. Resident R2 care plan dated 1/22/2022 states that resident needs medication setup and reminders in addition to medication management by facility including ordering medications –
Continued LIC 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2022

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 4

Control Number 21-AS-20220811091318

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: REDWOODS, THE	FACILITY NUMBER: 210102866
	VISIT DATE: 09/12/2022

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

resident is signed up for Pharmerica; physician’s assessment dated 12/31/2021 states that resident can’t store and/or administer medications; doctor’s orders dated 1/23/2022. Resident R2 missed the following medication: Losartan 50 mg daily from 8/2/2022 to 8/10/2022 – family member was contacted on 8/10/2022 and was able to bring a refill of 7 tablets and on 8/15/2022 facility was able to receive a refill for 3 tablets according with records and Centrally Stored Medication Records (CSMR); facility contacted pharmacy however wasn’t able to receive prescription; Elequilis missed from 4/23/2022 to 4/26/2022; and Amoldine missed from 5/22/2022 to 5/23/2022 – according with CSMRs and Medication Administration Records (MARs) with state that medications were not available. (see copy of records) Resident R3 physician’s assessment dated 8/25/2017 states that facility manages medication and orders from pharmacy – Pharmerica; resident R3 has missed the following medications due to medication “not available” (see copy of MARs): Omeprazole 20 ml once daily from 5/1/2022 to 5/5/2022 and 6/20/2022 to 6/30/2022, Omeprazole 40 ml once daily from 6/21/2022 to 7/13/2022 – records show that facility contacted pharmacy letting them know that “had run out of medication”, Amoldipane 2.5 mg once daily from 6/10/2022 to 6/14/2022 – records show fax to pharmacy stating “ran out of medication on 6/7/2022, Valsartan 160 mg once daily “not available” from 5/30/2022 to 6/14/2022. (see copy of records, LIC 811 confidential name list, LIC 9099-D). Administrator and staff S1 stated that they had knowledge of resident R1 missing medication on August 2022 and that it was due to Pharmerica waiting for a renew doctor’s order to refill; doctor had been contacted and submitted refill order to the wrong pharmacy. Facility didn’t learn that refill had been submitted to the wrong pharmacy until resident R1 had already missed 8 days of medication. In addition, facility didn’t not submit incident report for any of the missing medication for R1 and R3 as it is required by Title 22 Regulations # 87211 Reporting Requirements. R4 missed Calcium from 7/21/22 to 7/25/22 .(see case management datimg 9/12/2022) Based on observations, interviews and documentation reviewed, Department was able to prove that facility did not dispense medication as prescribed by doctor.

Continued LIC 9099-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 21-AS-20220811091318

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: REDWOODS, THE	FACILITY NUMBER: 210102866
	VISIT DATE: 09/12/2022

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

According with complaint allegation "Facility did not dispense medication as prescribed by doctor.” there were related observations made during visit. Based on LPA observations, file reviewed, and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

Appeal of Rights Given.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 21-AS-20220811091318

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: REDWOODS, THE	FACILITY NUMBER: 210102866
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/12/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/13/2022 Section Cited CCR 87465(a)(5)	1 2 3 4 5 6 7	87465(a)(5)Incidental Medical & Dental Care. This requirement isnot met as evidenced by: Based on interviews & record reviews facility didn't comply w/section cited above in 2 out of 4 residents for which medications	1 2 3 4 5 6 7	Facility to ensure that residents's medications will be filled in a timely matter to avoid missing meds. Facility to update and submit to Department policy and procedures on the process to fill medications on
	8 9 10 11 12 13 14	were not filled in a timely matter which poses an immediate health & safety risk to persons in care.Dep. learned that R2 had meds that werenot filled timely in August,April,May of 2022;R3 in May, June and July 2022. (see copies)	8 9 10 11 12 13 14	time including the staff title responsible for ordering & who to contact when problems arrive by POC date of 9/13/22. In addition, facility to submit med tech staff training on update procedures by 9/26/22 in order to clear.
	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: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 4