275202569-4-25-2022-26-AS-KHOS-CE6RM2-20220506130801

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 275202569
Report Date: 04/23/2022
Date Signed: 04/25/2022 09:19:31 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/24/2021 and conducted by Evaluator Albert Johnson

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20210924155331

FACILITY NAME:	CAREFIELD AT MADONNA GARDENS		FACILITY NUMBER:	275202569
ADMINISTRATOR:	PATRICIA KING		FACILITY TYPE:	740
ADDRESS:	1335 BYRON DR		TELEPHONE:	(831) 758-0931
CITY:	SALINAS	STATE: CA	ZIP CODE:	93901
CAPACITY:	88	CENSUS: 41	DATE:	04/23/2022
		UNANNOUNCED	TIME BEGAN:	12:12 PM
MET WITH:	Hamilton		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff not trained to administer medications
Staff gave resident wrong medication

INVESTIGATION FINDINGS:

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Allegation: Staff not trained to administer medications,

Based on records reviewed LPA was able to determine that Medtechs receive 8 hours of training and 16 hours of shadowing/ mentoring. LPA also determined that Medtechs are required to shadow with the mentor prior to administering medications.

Upon review of facility records LPA was able to establish that Medtech 1 did not received training on medication administration and was not provided shadowing for a medication error that occurred on 9/17/2021. On November 3rd, 9th and 10th of 2021, Medtech 1 administered medication and was not properly trained to provide medication administration according to the facility training requirements.
Continued**

Substantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2022

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 26-AS-20210924155331

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: CAREFIELD AT MADONNA GARDENS	FACILITY NUMBER: 275202569
	VISIT DATE: 04/23/2022

NARRATIVE

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Allegation: Staff gave resident wrong medication.

Based on records reviewed LPA was able to establish that R1 was given the wrong medication on 9/17/2021. The facility notified the Primary Care Physician and the family of R1. R1 was monitored throughout the day for any adverse reactions. The facility noted that there were no adverse reactions. The facility provided the department with an incident report dated 10/1/2021 which detailed the incident.

The preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. The following deficiencies were observed (see LIC 9099-D) and cited from the California Code of Regulations, Title 22.

Appeal rights and report given at the conclusion of the investigation.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20210924155331

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: CAREFIELD AT MADONNA GARDENS	FACILITY NUMBER: 275202569
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/23/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/25/2022 Section Cited CCR 87411(d)(4)	1 2 3 4 5 6 7	87411 Personnel Requirements (d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance:	1 2 3 4 5 6 7	Licensee shall provide an in-service from an outside vendor for staff on medication administration. The facility will provide the department with documentation that the staff have completed the training and provide the department with an agenda of which topics were addressed.
	8 9 10 11 12 13 14	(4) Knowledge required to safely assist with prescribed medications which are self administered. This requirement was not met as evidenced by records reviewed Medtech 1 was not properly trained prior to administering medication. This is an immediate heath and safety risk to residents in care.	8 9 10 11 12 13 14	The information shall be submitted to the department by the POC date of 4/25/2022. If additional time is needed the facility will submit a request for an extension before the POC date.
Type A 04/25/2022 Section Cited CCR 87465(a)(5)	1 2 3 4 5 6 7	Incidental Medical and Dental Care A plan for incidental medical and dental care shall be developed...The licensee shall assist residents with self administered medications as needed.	1 2 3 4 5 6 7	The facility shall locate an outside Vendor to conduct training to all employees who administer medication to clients on Medication Management
	8 9 10 11 12 13 14	This regulation was not met as evidence by: The licensee did not provide R1 with required refrigerated medication timely. Based on records reviewed, R1 was given four medication which were the wrong medication on 9/17/2021. This poses an immediate risk to residents in care.	8 9 10 11 12 13 14	The plan shall be submitted by 4/25/2022 with the Vendor's name and dates of training. This information shall be submitted to CCL by due 4/25/2022

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: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2022

LIC9099 (FAS) - (06/04)

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