210109022-4-11-2023-21-AS-KMOA-CR3U6B-20230420151806

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 210109022
Report Date: 04/11/2023
Date Signed: 04/11/2023 11:41:07 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
01/30/2023 and conducted by Evaluator Jill Nakagawa

COMPLAINT CONTROL NUMBER: 21-AS-20230130113850

FACILITY NAME:	NOVATO RESIDENTIAL SUPPORT SERVICES		FACILITY NUMBER:	210109022
ADMINISTRATOR:	ROBIN HUGHES		FACILITY TYPE:	735
ADDRESS:	1333 SEVENTH STREET		TELEPHONE:	(415) 897-7195
CITY:	NOVATO	STATE: CA	ZIP CODE:	94947
CAPACITY:	15	CENSUS: 15	DATE:	04/11/2023
		UNANNOUNCED	TIME BEGAN:	10:35 AM
MET WITH:	Robin Hughes, Administrator		TIME COMPLETED:	11:50 AM

ALLEGATION(S):

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Medications not given as prescribed
Licensee failed to report incidents

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jill Nakagawa, conducted an unannounced complaint visit to deliver the findings of a complaint investigation.

Complaint alleges that there have been multiple medication errors at the facility where residents have not received their required medications. Based on the medication record and physician's orders on file, there were 3 medication errors found during the time frame of this investigation. Two of the medication errors were due to a refill not being obtained in a timely manner, and the third medication error was simply listed as “missed”. All other medications and medication records reviewed were consistent with doctor's orders on file. After a thorough review of facility medication records, resident physician's orders, and interviews with medication aide, the preponderance of evidence standard has been met, therefore the above allegation is found to be
SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapter 1), are being cited on the attached LIC 9099D.
(continued on 9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023

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 21-AS-20230130113850

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: NOVATO RESIDENTIAL SUPPORT SERVICES	FACILITY NUMBER: 210109022
	VISIT DATE: 04/11/2023

NARRATIVE

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Continued from 9099

Complainant alleges Incident Reports have not been filed with CCL as required, and believes there has only been 1 report made over the last 8 months, but there have been multiple incidents that should have been reported. During staff interviews, LPA was informed that an Incident Report (IR) had not been submitted to Community Care Licensing (CCL) within the required timeframes per Regulation 80061 for multiple occurrences. The occurrences not reported were medication errors. Although the clients did not sustain any injury or harm due to the medication errors, the facility failed to ensure the health and safety of the clients in care. The LPA discussed reporting requirements, per regulations with the staff. After a review of records and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapters 1), are being cited on the attached LIC9099D.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 21-AS-20230130113850

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: NOVATO RESIDENTIAL SUPPORT SERVICES	FACILITY NUMBER: 210109022
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/11/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/11/2023 Section Cited CCR 80075(b)	1 2 3 4 5 6 7	80075 Health Related Services:(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee to ensure Clients receive the proper medication as ordered by physician. Licensee to schedule refresher training for all staff that assist with medications by POC date of 04/12/23.
	8 9 10 11 12 13 14	Based on records reviewed, Licensee did not ensure client received the correct medication. This poses an immediate Health, Safety or Personal rights risk to Clients in care.	8 9 10 11 12 13 14	Training to be completed by 04/22/23. Training material and staff sign in sheets to be submitted to CCL by 04/24/23.
Type B 04/11/2023 Section Cited CCR 80061(b)(1)(E)	1 2 3 4 5 6 7	80061 Reporting Requirements(b).. of any of the events specified in ...a written report containing information specified in (2)... within seven days following the occurrence of such event.(1)... (E) Any unusual incident...which threatens the ... safety of any client. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee will ensure that any unusual incident will be reported to CCLas specified in the regulation 80061. Training reviewing the Reporting Requirement Regulation to be completed by 04/22/23. Training materials and sign-in sheet to be submitted to CCL by XX/XX/XX.
	8 9 10 11 12 13 14	Based on review of medication administration records and filed incident reports by the facility to the State, the Licensee failed to report a medication error event to the RO. This poses a potential threat to the Health, Safety and Personal Rights risk to the clients in care.	8 9 10 11 12 13 14	Training materials and sign-in sheet to be submitted to CCL by 04/24/23.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023

LIC9099 (FAS) - (06/04)

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