216804010-2-8-2024-21-AS-VBEI-D2AUCF-20240209142752

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216804010
Report Date: 02/08/2024
Date Signed: 02/08/2024 12:36:47 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
11/02/2023 and conducted by Evaluator Caitlynn Felias

COMPLAINT CONTROL NUMBER: 21-AS-20231102122712

FACILITY NAME:	VINCENT, THE		FACILITY NUMBER:	216804010
ADMINISTRATOR:	SAHAR MOSALLA		FACILITY TYPE:	740
ADDRESS:	1 LAS GALINAS AVE		TELEPHONE:	(628) 243-3959
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY:	126	CENSUS: 72	DATE:	02/08/2024
		UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Regional Health and Wellness Director Roschelle Factor, Regional Operations Specialist, Sahar Mosalla		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Staff did not administer resident's medication as prescribed

INVESTIGATION FINDINGS:

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At approximately 9:50AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Complaint Investigation regarding the above allegation and met with Regional Health and Wellness Director Roschelle Factor, Regional Operations Specialist, Sahar Mosalla.

During the course of the Investigation, LPA requested and reviewed documents, conducted interviews, and made observations. Reporting party alleges that Staff did not administer resident’s medication as prescribed.
Reporting party stated that Resident 1’s (R1’s) Simbrinza eyedrop prescription was changed from twice a day to once a day for an unknown reason. Review of R1’s file showed that the facility received an electronic order from the pharmacy dated 12/16/2022. The pharmacy order stated for the Simbrinza eyedrops to be given once a day. File review showed that there was no physician’s order in R1’s file requesting for the change on how the medication was to be administered and also showed that the facility did not ask for clarification for the eyedrop prescription until June 2023.
Continued on LIC9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024

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-20231102122712

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: VINCENT, THE	FACILITY NUMBER: 216804010
	VISIT DATE: 02/08/2024

NARRATIVE

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Continued from LIC9099

Review of Facility’s Program Plan for Medication Management stated the following “written physician orders for all medications are maintained in the resident’s chart…” Staff interviews conducted stated that a physician order is to be received by the facility and faxed to the appropriate pharmacy for the medication to be filled. Based on review of documents, interviews conducted, and observations made, this allegation is Substantiated.

A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Facility conducted an in-service training covering Medication Management which reviewed Medication Orders and Changes on 01/25/2024. LPA was provided with a copy of training documentation and cleared the deficiency cited today, 02/08/2024, during visit.

Exit interview conducted. Plan of Corrections reviewed and developed with Regional Health and Wellness Director and Regional Operations Specialist. Copy of report, LIC9099D, Plan of Corrections, and Appeal Rights discussed and provided to Regional Health and Wellness Director and Regional Operations Specialist. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 5

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
11/02/2023 and conducted by Evaluator Caitlynn Felias

COMPLAINT CONTROL NUMBER: 21-AS-20231102122712

FACILITY NAME:	VINCENT, THE		FACILITY NUMBER:	216804010
ADMINISTRATOR:	SAHAR MOSALLA		FACILITY TYPE:	740
ADDRESS:	1 LAS GALINAS AVE		TELEPHONE:	(628) 243-3959
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY:	126	CENSUS: 72	DATE:	02/08/2024
		UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Regional Health and Wellness Director Roschelle Factor, Regional Operations Specialist, Sahar Mosalla		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Staff did not maintain accurate resident records

INVESTIGATION FINDINGS:

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At approximately 9:50AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Complaint Investigation regarding the above allegation and met with Regional Health and Wellness Director Roschelle Factor, Regional Operations Specialist, Sahar Mosalla.

During the course of the Investigation, LPA requested and reviewed documents, and made observations. Reporting party alleges that that staff did not maintain accurate resident records. Reporting party stated that the facility did not maintain accurate resident records for R1’s medication eyedrops. Reporting Party stated that the Facility’s Medication Administration Records (MAR) were signed by facility staff saying that R1’s Simbrinza eyedrops were administered when they were out of the community with their Responsible Party on 06/22/2023. Reporting Party stated that it would be impossible for facility staff to have administered the eyedrops since R1 was off-site when they needed to be given.

Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 21-AS-20231102122712

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: VINCENT, THE	FACILITY NUMBER: 216804010
	VISIT DATE: 02/08/2024

NARRATIVE

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Continued from LIC9099

Review of Facility’s policy “Transferring Medication for Home Visits and Outings” stated the following “When a resident leaves the community for a short period of time during which only one dose of medication is needed, the Designated staff person gives the medications to a responsible party in an envelope (or similar container) labeled with the resident’s name, name of medication(s), and instructions for administering the dose…the person entrusted with the medications agrees in writing as to the amount of medication received on behalf of the resident and the appropriate dosing amount and schedule.” Review of R1’s file indicated that R1’s eyedrops and medication instructions were provided to R1’s Responsible Party so it could be administered to R1 while out of the community. Based on review of documents and observations made, this allegation is Unsubstantiated.

A finding that the complaint is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

Exit Interview conducted. Copy of Report discussed and provided to Administrator. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 21-AS-20231102122712

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: VINCENT, THE	FACILITY NUMBER: 216804010
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/08/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/09/2024 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care(a) A plan... shall be developed... The plan shall... provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced	1 2 3 4 5 6 7	Licensee conducted In-Service Training on Medication Management which reviewed Medication Orders and Changes for all medication technicians on 01/25/2024. Deficiency cleared during visit.
	8 9 10 11 12 13 14	by: Based on document review, interviews, and observations made, the Licensee did not comply with the section cited above. R1 did not have a physician's order on file to verify a medication change that was being given. This poses an immediate health, safety, or personal rights risk to residents in care.	8 9 10 11 12 13 14
	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: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024

LIC9099 (FAS) - (06/04)

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