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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 247202427
Report Date: 05/24/2022
Date Signed: 05/24/2022 12:43:56 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, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/31/2021 and conducted by Evaluator Mary Garza
COMPLAINT CONTROL NUMBER: 24-AS-20210831135132
FACILITY NAME:TERRIE'S TLC SENIOR HOME IIFACILITY NUMBER:
247202427
ADMINISTRATOR:RHODES, THERESE ANNEFACILITY TYPE:
740
ADDRESS:1317 E BROOKDALE DR.TELEPHONE:
(209) 726-0548
CITY:MERCEDSTATE: CAZIP CODE:
95340
CAPACITY:6CENSUS: 1DATE:
05/24/2022
UNANNOUNCEDTIME BEGAN:
12:11 PM
MET WITH:Licensee, Therese RhodesTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Resident’s medication misplaced.
INVESTIGATION FINDINGS:
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On 5/24/2022 Licensing Program (LPA) M. Garza arrived at facility unannounced to deliver complaint findings. LPA was met by facility staff, Christine Jarvise. Licensee was contacted and arrived a short time later. LPA was COVID pre-screened prior to entry to facility. LPA allowed entry to facility and advised reason for visit. LPA toured facility. LPA completed health and safety check on 1 resident in care. Resident observed in common area watching television.

Department conducted interviews (facility staff, hospice, RP). LPA requested and reviewed records. Hospice records indicated R1 was missing 7 morphine tablets and 8 Tylenol tablets. Licensee/Staff could not account for them and did not locate them at a later time. Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

A deficiency has been cited in accordance with the California Code of Regulations, Title 22. See 809D. Exit interview was conducted. A copy of this report, appeal rights and deficiency were given.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: (559) 365-9009
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022
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 2
Control Number 24-AS-20210831135132
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: TERRIE'S TLC SENIOR HOME II
FACILITY NUMBER: 247202427
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/25/2022
Section Cited
CCR
87465(h)(2)
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87465 87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2)Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
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Per Licensee a locked box for all narcotics has been purchased. Medication have to be signed in and out separately. Training was completed with all staff. Medications are being checked 1 to 2 times weekly by Licensee. Report any inconstiancies of medication to CCL in a timely manner.
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This requirement was not met as evidence by record reviewed: LPA reivewed the Hospice records of R1 which showed that R1 was missing 7 morphine tablets and 8 tylonol tablets. Licensee/Staff could not locate them/find them at a later time. This posses a potential Health and Safety risk to residents 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.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: (559) 365-9009
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022
LIC9099 (FAS) - (06/04)
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