306000889-1-24-2024-22-AS-SSAS-CZYUY9-20240130145933

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306000889
Report Date: 01/24/2024
Date Signed: 01/24/2024 03:12:46 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/19/2022 and conducted by Evaluator Kevin Saborit-Guasch

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20220119151449

FACILITY NAME:	SENIOR LIVING COMMUNITY FOR THE EASTERN STAR IN CA		FACILITY NUMBER:	306000889
ADMINISTRATOR:	JO DEE GIBSON		FACILITY TYPE:	741
ADDRESS:	16850 E. BASTANCHURY ROAD		TELEPHONE:	(714) 577-9281
CITY:	YORBA LINDA	STATE: CA	ZIP CODE:	92886
CAPACITY:	76	CENSUS: 29	DATE:	01/24/2024
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Lida Spicer, Wellness Director Kat Farris, Executive Director		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Residents medication is being mishandled

INVESTIGATION FINDINGS:

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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of delivering findings into the investigation of the allegation listed above. LPA was greeted and granted entry by front desk staff after explaining the purpose of the visit.

The initial complaint investigation visit was led by LPA Kathrina Chin on January 25, 2022. LPA met with the Director of Resident Services and gathered pertinent documents for resident R1. A follow-up visit was conducted by LPA Saborit-Guasch on October 17, 2023. LPA interviewed the facility's Wellness Director as well as requested, obtained and reviewed the complete Medication Administration Records for resident R1 covering the admission period from December 2020 until March 2022. Records obtained include physician orders for medication and topical treatments as well as copies of the paper and electronic records documenting the administration process.

CONTINUED ON FORM LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024

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 22-AS-20220119151449

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SENIOR LIVING COMMUNITY FOR THE EASTERN STAR IN CA	FACILITY NUMBER: 306000889
	VISIT DATE: 01/24/2024

NARRATIVE

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CONTINUED FROM FORM LIC9099
Additional evidence was gathered during the investigation process and witness interviews conducted.

Regarding the allegation that Residents medication is being mishandled, the following has been concluded: Based on interviews conducted and a review of the Medication Administration Records (MAR) provided by the facility, it was determined that all medications dispensed had a corresponding prescription/physician order as required by Title 22 Regulations. Title 22 regulations do not require pre-approval from or notification to the attorney-in-fact prior to dispensation as long as physician orders are on file. However, it was also determined during the investigation that a request to discontinue the administration of Depakote was made by the resident's attorney-in-fact and implemented effective January 25, 2022 per the MAR and physician order reviewed. Later blood tests performed on March 9, 2022 after R1 was hospitalized at Saddleback Hospital show blood levels for Valproic Acid (Depakote) to be below 3ug/ML which was determined to be consistent with the medication being discontinued per the request expressed to the facility. Pharmacy invoices provided also confirm that no additional billing for that specific medication is present after the discontinuation.

As a result, the allegation is found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report was provided to a facility representative.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024

LIC9099 (FAS) - (06/04)

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