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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 275294182
Report Date: 10/21/2021
Date Signed: 10/21/2021 03:57:27 PM



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
09/16/2020 and conducted by Evaluator Marybeth Donovan
COMPLAINT CONTROL NUMBER: 26-AS-20200916101458
FACILITY NAME:DRAKE HOUSEFACILITY NUMBER:
275294182
ADMINISTRATOR:JULIE HUYNHFACILITY TYPE:
740
ADDRESS:399 DRAKE AVENUETELEPHONE:
(831) 643-9069
CITY:MONTEREYSTATE: CAZIP CODE:
93940
CAPACITY:55CENSUS: 50DATE:
10/21/2021
UNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Jenny LombarteTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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9
Staff mismanaged resident’s medication
Staff spoke inappropriately to resident

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Marybeth Donovan arrived unannounced to deliver the complaint findings for the above allegations. LPA met with Jenny Lombarte Assistant Administrator.

The Department received notice of the above complaint allegations on 9/16/2020.
On 9/25/2020 Licensing Program Analyst (LPA) Marybeth Donovan conducted a Tele-Visit to open the 10 Day Complaint investigation.

On 6/24/2021 conducted an on site complaint visit. LPA reviewed facility records, resident records to include physician's reports, appraisal needs and services plans, progress notes, and medication administration records.

Between 9/25/2020 and 10/21/2021 4 staff and 12 residents were interviewed. 4 of 4 staff stated that there no mismanagement of R1's medications.

Page 1 of 2
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021
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 26-AS-20200916101458
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: DRAKE HOUSE
FACILITY NUMBER: 275294182
VISIT DATE: 10/21/2021
NARRATIVE
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11 of 12 residents stated that they have not had any issues with their medication administration nor are they aware of any other resident having issues with medication administration. 1 of 12 residents R1 was unable to provide details of any incident of medication mismanagement.

4 of 4 staff stated that they did not speak inappropriately to residents and were unaware of any staff speaking inappropriately to residents. 11 of 12 residents are unaware of any situation in which staff spoke inappropriately to them or any other resident. 1 of 12 residents, R1 was unable to provide details of an incident in which staff spoke inappropriately to resident.

Records reviewed included residents physician’s report, progress notes, appraisal needs and services plan and medication administration records to include PRN medication records. The PRN medication records did not record any errors or issues with the administration of PRN medications.

This Department has investigated the complaint allegation listed. Based on interviews, review of records, the The Department has found that the complaint allegation is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

Exit interview conducted with Jenny Lombarte Assistant Administrator and a copy of this report provided.

SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021
LIC9099 (FAS) - (06/04)
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