306004207-7-27-2023-28-AS-WSHO-CUR7VT-20230815220027

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004207
Report Date: 07/27/2023
Date Signed: 07/27/2023 03:10:55 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/24/2023 and conducted by Evaluator Luis Mora

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230724145447

FACILITY NAME:	MERCEDES DIAZ HOMES INC - DAVENRICH		FACILITY NUMBER:	306004207
ADMINISTRATOR:	NAYELI NOLASCO		FACILITY TYPE:	735
ADDRESS:	11102 DAVENRICH RD		TELEPHONE:	(562) 863-1932
CITY:	SANTA FE SPRINGS	STATE: CA	ZIP CODE:	90670
CAPACITY:	5	CENSUS: 5	DATE:	07/27/2023
		UNANNOUNCED	TIME BEGAN:	01:14 PM
MET WITH:	Rosie Reynoso – Administrator		TIME COMPLETED:	03:25 PM

ALLEGATION(S):

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Staff did not administer client's medication as prescribed.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced initial complaint visit to determine the validity of the above-mentioned allegation. LPA met with Rosie Reynoso and explained the reason for the visit.

The investigation consisted of the following: LPA Mora obtained copies of staff and client rosters. LPA reviewed Client 1 - Client 5 (C1 - C5) July 2023 medication and MARs from March 2023 - June 2023. LPA interviewed Administrator, Staff 1 - Staff 2 (S1 - S2), Client 1 - Client 4 (C1 - C4).

The investigation revealed the following: regarding the allegation "staff did not administer client's medication as prescribed”, it is alleged that C1's morning medication, Everolimus 0.75mg, is prescribed as two tablets per day, and only one pill was dispensed to the client on the morning of 05/30/23. Interview with Administrator and staff confirmed the medication error. Facility conducted 4 in-service trainings with all staff regarding medication on 05/30/23, 05/31/23, 06/02/23 and 06/08/23. (Continue to LIC 9099-C)

Substantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

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 28-AS-20230724145447

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MERCEDES DIAZ HOMES INC - DAVENRICH	FACILITY NUMBER: 306004207
	VISIT DATE: 07/27/2023

NARRATIVE

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Per review July 2023 medication and MARs from March 2023 - June 2023 for all clients the LPA did not see any other medication errors.

Based on LPA's interviews, records reviewed and observations, the preponderance of evidence standard has been met, therefore the allegation is found SUBSTANTIATED. California Code of Regulations Title 22, Division 6, Chapter 1 are being cited on the attached LIC 9099-D.

Exit interview held and a copy of the report and appeal rights was provided.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20230724145447

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MERCEDES DIAZ HOMES INC - DAVENRICH	FACILITY NUMBER: 306004207
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/27/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/28/2023 Section Cited CCR 80075(b)(4)	1 2 3 4 5 6 7	Health Related Services - (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications... This regulation has not been met as evidenced by:	1 2 3 4 5 6 7	Facility is to ensure that Title 22 Section 80075 regulations are met at all times. Additionally, an in-service training is to be conducted regarding medication with all staff and submit proof of training to CCLD.
	8 9 10 11 12 13 14	Based on interviews and records review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. The medication Everolimus 0.75mg, was not given as prescribed for C1 on the morning of 05/30/23.	8 9 10 11 12 13 14	Facility already conducted in-service trainings regarding medication on 05/30/23, 05/31/23, 06/02/23 and 06/08/23 with all staff.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

LIC9099 (FAS) - (06/04)

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