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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 275202260
Report Date: 08/29/2023
Date Signed: 08/30/2023 09:52:55 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 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
04/07/2023 and conducted by Evaluator David Ayers
COMPLAINT CONTROL NUMBER: 24-AS-20230407155801
FACILITY NAME:ARCHWAY OF CARMELFACILITY NUMBER:
275202260
ADMINISTRATOR:CYRIL TUPINOFACILITY TYPE:
740
ADDRESS:3262 TAYLOR ROADTELEPHONE:
(831) 269-4164
CITY:CARMELSTATE: CAZIP CODE:
93923
CAPACITY:6CENSUS: 6DATE:
08/29/2023
UNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Maria Carrillo-caregiverTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff gave resident crushed medication(s) without a doctor's order.
INVESTIGATION FINDINGS:
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On 8/29/2023, Licensing Program Analyst (LPA) D. Ayers conducted an unannounced complaint inspection. LPA met with caregiver Maria Carrillo and contacted Licensee Cyril Tupino. The licensee agreed that staff could sign the reports on his behalf. The purpose of this visit is to deliver the finding of the investigation completed by the Department. LPA conducted a tour of the facility, interior and exterior to ensure there are no potential or immediate health and safety risk at the facility.

During the course of the investigation, the department inspected the facility, conducted interviews, and reviewed records. Based off of interviews and records, facility staff did crush Resident 1's(R1) medications and place them in food. Although facility staff claimed that this was due to R1's inability to swallow and was done at the request of R1's responsible party, medications were crushed without a physician's order.

Continued on LIC9099C

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: David AyersTELEPHONE: 559-498-4163
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023
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 24-AS-20230407155801
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: ARCHWAY OF CARMEL
FACILITY NUMBER: 275202260
VISIT DATE: 08/29/2023
NARRATIVE
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Based on the interviews conducted, documentation obtained and reviewed, and the information received during this investigation, the preponderance of evidence standard has been met; therefore, the above allegations are found to be substantiated at this time.

Per the California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, the following deficiency was observed and cited on LIC 9099-D. Failure to correct the deficiency may result in civil penalties.

An exit interview was conducted, and a copy of this report provided. Appeal Rights (LIC 9058) was provided to facility staff, whose signature below confirms receipt of these rights.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: David AyersTELEPHONE: 559-498-4163
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 24-AS-20230407155801
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: ARCHWAY OF CARMEL
FACILITY NUMBER: 275202260
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/05/2023
Section Cited
CCR
87465(a)(5)(D)
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87465 Incidental Medical and Dental Care: (a)(5)(D)Assistance with self-administration does not include forcing a resident to take medication, hiding or camouflaging medications in other substances without the resident's knowledge and consent, or otherwise infringing upon a resident's right to refuse to take a medication. This Requirement was not met as evidenced by:
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Licensee agreed to provide staff with training regarding proper handling of medications. Licensee agreed to provide statement of understanding regarding requirements for physician orders for medications.
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Based on interviews comducted and records reviewed, facility staff crushed R1's medications and placed them in food without having physician's orders to do so for 1 out of 5 residents, which presents 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: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: David AyersTELEPHONE: 559-498-4163
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3