306003060-10-25-2023-22-AS-MSTC-CXSNGR-20231121092734

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306003060
Report Date: 10/25/2023
Date Signed: 10/25/2023 01:44:06 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
10/20/2023 and conducted by Evaluator Jessica Cho

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20231020160710

FACILITY NAME:	WEST GLENN MANOR		FACILITY NUMBER:	306003060
ADMINISTRATOR:	ROSARIO NAZARENO		FACILITY TYPE:	740
ADDRESS:	7242 WESTMINSTER BLVD.		TELEPHONE:	(714) 898-2131
CITY:	WESTMINSTER	STATE: CA	ZIP CODE:	92683
CAPACITY:	98	CENSUS: 87	DATE:	10/25/2023
		UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Rosario Nazareno- Licensee/Administrator Brian Nazareno- Assistant Administrator		TIME COMPLETED:	01:50 PM

ALLEGATION(S):

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Facility is knowingly administering a medication that a resident is allergic to.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jessica Cho arrived unannounced for the purpose to investigate into the above allegation. LPA was greeted and allowed entry by Assistant Administrator (AA) Brian Nazareno. Licensee/Administrator (L/A) Rosario Nazareno arrived shortly after to assist LPA with the investigation. During today's visit, LPA obtained interviews with resident/staff and copies of pertinent facility/resident records that were reviewed on site. The following was revealed during the course of the investigation:

It is alleged that the facility is knowingly administering a medication that a resident is allergic to. While conducting a file review, Pencillin (PCN) is a known drug allergy for Resident #1 (R1) that was documented on two forms: Identification and Emergency Information (LIC601) dated January 2, 2023 and the Physician's Report dated April 18, 2023. Per the Medication Administration Record (MAR), LPA observed R1's allergies were not noted on the form. Augmentin, a derivative of PCN, was prescribed by the primary care physician and administered on October 12, 2023 and terminated on October 14, 2023 as noted on the MAR. Three out of the three staff confirmed the administration of Augmentin in

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

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-20231020160710

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: WEST GLENN MANOR	FACILITY NUMBER: 306003060
	VISIT DATE: 10/25/2023

NARRATIVE

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accordance with the doctor's orders and due to R1's PCN allergy not mentioned on the MAR produced by the pharmacy. LPA is able to establish that although that the facility should have identified and cross-checked R1's allergies, facility did not knowingly administer a medication R1 was allergic to.

Therefore, based on the interviews which were conducted and the records that were reviewed, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the following allegation: Facility is knowingly administering a medication that a resident is allergic to is deemed UNSUBSTANTIATED.

An exit interview was conducted with Licensee/Administrator Rosario Nazareno Assistant Administrator Brian Nazareno, and a copy of this report including the LIC9099-C and the LIC811 were provided at the end of the visit.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

LIC9099 (FAS) - (06/04)

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