295001463-7-29-2021-27-AS-MSEY-C5QLPR-20210809085621

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 295001463
Report Date: 07/29/2021
Date Signed: 07/29/2021 11:28:21 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/24/2021 and conducted by Evaluator Melana Llopis

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20210324160544

FACILITY NAME:	SIERRA VIEW MANOR		FACILITY NUMBER:	295001463
ADMINISTRATOR:	MORGAN WHINERY		FACILITY TYPE:	740
ADDRESS:	120 DORSEY DRIVE		TELEPHONE:	(530) 273-4849
CITY:	GRASS VALLEY	STATE: CA	ZIP CODE:	95945
CAPACITY:	58	CENSUS: 29	DATE:	07/29/2021
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Administrator, Lisa Vixie Winget		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Untrained staff administering medication to hospice residents
Facility did not properly of disposing medications

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Melana Llopis arrived at the facility unannounced on 7/29/2021 to deliver complaint findings. Prior to visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted licensee and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: required facemask.
LPA met with Administrator Lisa Vixie Winget and explained the purpose of the visit.

Throughout the course of the investigation, the Department conducted on-site visits, reviewed documentation and conducted interviews.

Results are as follows:
***Continuation on LIC9099C***

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melana Llopis	TELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021

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 5

Control Number 27-AS-20210324160544

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: SIERRA VIEW MANOR	FACILITY NUMBER: 295001463
	VISIT DATE: 07/29/2021

NARRATIVE

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Allegation: Untrained staff administering medication to hospice residents.

On 7/21/2021 LPA Llopis and LPA Mknelly conducted a facility visit and spoke with two (2) of two (2) staff who were working around March 2021. Staff (S1) stated they were working as a medical technician since March 2021. S1 stated they did not complete their training and were not required to complete their training by the Administrator during that time period. S1 stated since the new management has taken over, S1 stated they feel they are fully trained and equipped. LPA Llopis reviewed training on 07/27/2021 for the two (2) medical technicians working during that time period and observed the following: Former Administrator did not have valid certification for medication training.
This allegation is being SUBSTANTIATED.

Allegation: Facility did not properly dispose medications.

On 07/21/2021 LPA Llopis and LPA Mknelly spoke with staff, S1 and S2. Staff stated they found closets of medication that were suppose to be thrown out seven days past expiration date during March 2021. Staff also stated they were told by the former facility Administrator that only one (1) individual needed to be present during the disposal of medication and only one (1) individual needed to sign off on the disposal.
This allegation is being SUBSTANTIATED.

As a result, deficiencies are being cited today and can be found on LIC9099-D, per California code of regulations, title 22.

Exit interview conducted, copy of report and appeal rights provided.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melana Llopis	TELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/24/2021 and conducted by Evaluator Melana Llopis

COMPLAINT CONTROL NUMBER: 27-AS-20210324160544

FACILITY NAME:	SIERRA VIEW MANOR		FACILITY NUMBER:	295001463
ADMINISTRATOR:	MORGAN WHINERY		FACILITY TYPE:	740
ADDRESS:	120 DORSEY DRIVE		TELEPHONE:	(530) 273-4849
CITY:	GRASS VALLEY	STATE: CA	ZIP CODE:	95945
CAPACITY:	58	CENSUS: 29	DATE:	07/29/2021
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Administrator, Lisa Vixie Winget		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Facility not properly documenting medications that were administered
Facility is not properly following medication management protocol upon new resident intake.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Melana Llopis arrived at the facility unannounced on 07/29/2021 to deliver complaint findings. Prior to visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted licensee and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: facial mask.
LPA met with Administrator and explained the purpose of the visit.

Throughout the course of the investigation, the Department reviewed documentation and conducted interviews.

The results are as follows:
***Continuation on LIC9099C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melana Llopis	TELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 27-AS-20210324160544

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: SIERRA VIEW MANOR	FACILITY NUMBER: 295001463
	VISIT DATE: 07/29/2021

NARRATIVE

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Allegation: Facility did not properly document medications that were administered

On 07/21/2021 LPA spoke with the new Administrator. Administrator stated they were "cleaning up a lot of things that were going on at the facility under previous management." Administrator stated the documentation of things needed to be more organized. LPA spoke with two (2) of two (2) staff who were working. Staff stated medical technicians were documenting when medication was being administered, however the former administrator was not consistent when signing out medication. On 7/21/2021 LPA Llopis reviewed R1, R2 and R3's medication records and centrally stored medication records and observed the following: on 03/29/2021, R2's MARS indicates a medication for R2 was not signed off. On 3/2/2021 and 3/22/2021, R1's MARS indicates medication for R2 was not signed off. No further evidence could be provided.
Allegation is being UNSUBSTANTIATED.

Allegation: Facility is not properly following medication management protocol upon new resident intake
On 07/21/2021, LPAs reviewed residents (R1, R2 and R3)'s records. LPAs found that on 01/27/2020 R2 moved into the facility and was able to verbally indicate when they needed a PRN medication. LPAs observed R2 has been on hospice since 2/13/2021. Two (2) of two (2) staff interviewed stated R2 is not able to verbally communicate their needs as clear as when R2 first moved in. LPA Mknelly suggested a new evaluation for R2 be conducted to ensure their PRN authorization form is up to date. No further evidence could be provided to suggest the facility is not following the medication management protocol upon new resident intake.

Due to the above information, the Department finds the allegations listed above to be UNSUBSTANTIATED, meaning that although the allegation(s) may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred, and the findings are unsubstantiated.

An exit interview was conducted, copy of report and appeal rights provided.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melana Llopis	TELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 27-AS-20210324160544

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: SIERRA VIEW MANOR	FACILITY NUMBER: 295001463
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/29/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/30/2021 Section Cited CCR 87411(d)(4)	1 2 3 4 5 6 7	87411 Personnel Requirements - General (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 stated they have verified how staff are administering medication. Licensee agrees to ensure all staff administering medication have completed their training. Proof of completion of training for all staff administering medication to be sent to CCL by POC date.
	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: two (2) of two (2) staff did not receive adequate training for administering medications. This put residents in care at an immediate health, safety and personal	8 9 10 11 12 13 14	rights risk.
Type B 08/09/2021 Section Cited CCR 87465(i)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (i) Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility... shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record...	1 2 3 4 5 6 7	Licensee states they have reviewed the regulation requirements regarding disposing medications. Licensee has reviewed medication disposal requirements with all staff responsible for disposing medication. Licensee agrees to send proof to CCL that all staff have reviewed the proper procedure for medication disposal by POC date.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Staff did not dispose of medication timely and facility administrator did not have another adult present when destroying medication in the facility. This put residents in care at a potential health, safety and personal rights risk.	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: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melana Llopis	TELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021

LIC9099 (FAS) - (06/04)

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