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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216803577
Report Date: 01/31/2024
Date Signed: 01/31/2024 01:35:12 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, 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
12/21/2023 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20231221135708
FACILITY NAME:WALDO HOUSEFACILITY NUMBER:
216803577
ADMINISTRATOR:LOTT, SHERIFACILITY TYPE:
735
ADDRESS:55 WALDO COURTTELEPHONE:
(415) 271-3304
CITY:SAUSALITOSTATE: CAZIP CODE:
94965
CAPACITY:5CENSUS: 4DATE:
01/31/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Paula Sifflet-Regional ManagerTIME COMPLETED:
01:40 PM
ALLEGATION(S):
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Medications are not administered per Dr's Order
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alviso conducted a complaint visit, on 1/31/2024 at approximately 10:00am and met with Direct Support Staff, Nia Tigerino.There was another staff on duty, Angel Solis. Three (3) clients were on-site, and one (1) client was at a Doctor appointment. Staff Nia contacted administration staff to notify them of the LPA's arrival. Regional Manager Paula Siffit arrived to meet with the LPA.

The LPA reviewed client records, facility medication logs/records, obtained copies of documents, conducted interviews with staff, and other related parties; The investigation revealed that clients (C1, C2, C3) have PRN medications prescribed by their Physician for client agitation. In review of document in medication records, PRN Criteria for each client, in summary the following is some of what's on the document: Not sleeping after 10pm, not sleeping, staying in bed and/or in their room, if client is in their room, quiet, prompt them to go to sleep, loud in the house, repeatedly coming out of their room with requests/needs.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024
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 21-AS-20231221135708
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: WALDO HOUSE
FACILITY NUMBER: 216803577
VISIT DATE: 01/31/2024
NARRATIVE
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Per review of records, clients have received the PRN medication for not going to sleep and/or repeated requests. Medication review of records showed C2 missed prescribed medications, two (2), on 12/7, 12/12, and 12/15, in 2023; Reason written for missed dosage of medications, the facility didn't have it/not filled and on-site. PRN medications reviewed are prescribed for agitation. Regional Manager Paula stated to the LPA that PRN's are to be provided to clients as last resort not right away, and agreed the documentation "PRN Criteria" is confusing, in when the agitation medication is to be provided. LPA reviewed findings of the complaint with Paula Siffit, and showed facility documents that support a violation(s) has occurred.

Based on LPA interviews, and review of information obtained, the investigation has revealed that the allegation of "Medications are not administered per Dr's Order", has been substantiated.

Due to the substantiation of the allegation, a citation will be cited today, Health Related Services(b)(5)(A)(B) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. If the client's physician has stated in writing that the client 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 client with self-administration, providing all of the following requirements are met: There is a written direction from a physician, on a prescription blank, specifying the name of the client, the name of the medication, all of the information specified in Section, dosage instructions. Once ordered by the physician the medication is given according to the physician's directions, see LIC9099D.

The preponderance of evidence standard has been met, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited.
Failure to correct deficiencies by due dates, may result in additional deficiency citations and/or civil penalties being assessed

Exit interview conducted with RM Paula Sifflet.
Appeal Rights provided to Paula Siffet.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20231221135708
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: WALDO HOUSE
FACILITY NUMBER: 216803577
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/01/2024
Section Cited
CCR
80075(b)(5)(A)(B)
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Health Related Services(b)(5)(A)(B) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. If the client's physician has stated in writing that the client 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 client with self-administration, providing all of the following requirements are met: There is a written direction from a physician, on a prescription blank, specifying the name of the client, the name of the medication, all of the information specified in Section, Section 80075(e), dosage instructions. Once ordered by the physician the medication is given according to the physician's directions,
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Administrator to ensure that all staff have an in-service training on assiting client's with all medications including PRN's, as needed & ordered by the Physician. Ensure PRN records are complete, accurate, and in-line with Dr's Orders. Ensure staff are documenting in PRN log all required information. Submit proof of training by 2/12/24.
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Per review of records, clients have received the PRN agitation medication for not going to sleep by 10pm, coming out of their room and/or repeated requests. Medication review of records showed C2 missed prescribed medications, two (2), on 12/7, 12/12, and 12/15, in 2023; Reason written for missed dosage of medications, This is an immediate risk to H&S and personal rights of the clients in care.
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Submit copies of new PRN Criteria document, and copy of PRN log the facility will be using when providing PRN's to clients. Submit plan of future compliance-all due by 2/12/24.
Submit plan of correction (POC) dueby 2/1/24.
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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.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3