275202569-4-12-2024-24-AS-BCHN-D5GL8K-20240521083202

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 275202569
Report Date: 04/10/2024
Date Signed: 04/12/2024 09:55:24 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 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
04/04/2024 and conducted by Evaluator Sarah Hurt

COMPLAINT CONTROL NUMBER: 24-AS-20240404121645

FACILITY NAME:	MADONNA GARDENS		FACILITY NUMBER:	275202569
ADMINISTRATOR:	TYLER BRANES		FACILITY TYPE:	740
ADDRESS:	1335 BYRON DR		TELEPHONE:	(831) 758-0931
CITY:	SALINAS	STATE: CA	ZIP CODE:	93901
CAPACITY:	88	CENSUS: 57	DATE:	04/10/2024
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Administrator, Tyler Barnes		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff did not distribute residents' medications as prescribed
Staff do not report incidents to appropriate parties

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to open a complaint on the allegations listed above. LPA Hurt met with Facility Administrator Tyler Barnes, and explained the purpose of today's visit.

Regarding the allegation Staff 1 did not distribute residents' medications as prescribed.Resident 1 was not given medication on 04/07/24, and 04/08/2024. Medication Administration Records document "med not available." It is not clear why Resident 1 was not given medication as the medication is available in the facility medication cart. Based on LPA interview conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Continued...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah Hurt	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024

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 24-AS-20240404121645

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: MADONNA GARDENS	FACILITY NUMBER: 275202569
	VISIT DATE: 04/10/2024

NARRATIVE

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Continued..

Regarding the allegation Staff do not report incidents to appropriate parties. Facility did not notify State Licensing or Resident 1's Responsible Parties of missed mediations on 04/07/24, 04/08/2024. Based on interviews conducted, and facility records reviewed the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

The following Deficiencies are being cited Per Title 22 Regulations.

Exit interview conducted with Administrator, Tyler Barnes, and a copy of this report, along with appeals rights provided.

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah Hurt	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 24-AS-20240404121645

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: MADONNA GARDENS	FACILITY NUMBER: 275202569
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/10/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/11/2024 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. The following requirement has not been met as evidenced by:	1 2 3 4 5 6 7	Administrator will conduct training with facility Staff 1 on medication administration, and submit proof to LPA by 04/11/2024 POC date.
	8 9 10 11 12 13 14	Resident 1 was not given medication on 04/07/2024, and 4/08/2024, which poses an immediate, heatlh, safety, or personal rights risk to residents in care.	8 9 10 11 12 13 14
Type B 04/24/2024 Section Cited CCR 87211(a)(d)	1 2 3 4 5 6 7	87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D)Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. The following requirement has not been met as evidenced by:	1 2 3 4 5 6 7	Administrator will conduct training with staff on Reporting Requirements and submit proof to LPA by POC date of 04/24/2024.
	8 9 10 11 12 13 14	The facility did not report Resident 1's missed medications to State Licensing, or Resident 1's Responsible party, which poses a potential, health, safety, or personal rights risk to residents in care.	8 9 10 11 12 13 14

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 Chan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah Hurt	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024

LIC9099 (FAS) - (06/04)

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