306004520-3-10-2025-22-AS-LMOA-DES2W6-20250314174501

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004520
Report Date: 03/10/2025
Date Signed: 03/10/2025 04:28:37 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
07/30/2024 and conducted by Evaluator Jessica Cho

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20240730113333

FACILITY NAME:	MERIDIAN AT LAGUNA HILLS		FACILITY NUMBER:	306004520
ADMINISTRATOR:	MARIA ROSSI		FACILITY TYPE:	740
ADDRESS:	24552 PASEO DE VALENCIA BLDG A		TELEPHONE:	(949) 581-6111
CITY:	LAGUNA HILLS	STATE: CA	ZIP CODE:	92653
CAPACITY:	0	CENSUS: 66	DATE:	03/10/2025
		UNANNOUNCED	TIME BEGAN:	08:33 AM
MET WITH:	Eric Jensen- Executive Director		TIME COMPLETED:	04:50 PM

ALLEGATION(S):

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Untrained staff are administering medications.
Insufficient staff to meet the residents' needs.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jessica Cho continued the visit after delivering the findings for complaint control number: 22-AS-20221221195315. The purpose of today's visit is to continue the investigation and deliver the findings into the above allegations. LPA met with Executive Director (ED) Eric Jensen and explained the reason for the visit. During the course of the investigation, LPA interviewed six residents and five staff and obtained the following documentation: Resident Rosters, Personnel Report Summary, Staff Contacts, June 2024 Staff Schedule, Staff training records, Face Sheets, Medication Policies and Procedures, Physician's Reports, medication physician orders, Medication Adminstration Logs, pay roll stubs, and pertinent hospice records.

The investigation revealed the following:

Regarding the allegation, Untrained staff are administering medications, it was reported that caregivers administered Morphine to Resident #1 (R1).

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2025

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-20240730113333

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: MERIDIAN AT LAGUNA HILLS	FACILITY NUMBER: 306004520
	VISIT DATE: 03/10/2025

NARRATIVE

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R1 was admitted to the facility on June 30, 2018 and was admitted to hospice on November 18, 2021. Based on the review of the medical records, Morphine was prescribed and given as ordered by the physician noted on the order dated June 15, 2024. R1 received Morphine from June 15 to June 18, 2024. Based on the interviews conducted six out of six residents did not corroborate the allegation and five out of five staff revealed Medication Technicians (MTs) who are also cross trained as caregivers are/were authorized to access and administer medications. Five out of five staff indicated that Morphine, being a controlled substance, were given to R1 by MTs after receiving on the job training from hospice and was only administered as needed with approval. The hospice care plan dated May 13, 2024 approved facility staff to administer Morphine. LPA verified MTs signing off after each dose of Morphine was given to R1 per the Controlled Drug Medication Administration Record (MAR). LPA confirmed none of the names listed on the MAR belonging to a caregiver. LPA also verified per the staff training records all five staff having proper training to administer medications during the in-services on March 27, April 6, and April 8, 2024.

Regarding the allegation, insufficient staff to meet the residents' needs, it was reported that 2 caregivers are on schedule during the day shift and 1 caregiver for the night shift affecting the residents' care. Based on the interviews conducted on August 6, 2024, five of the five staff confirmed having 3 caregivers during the day and 1 caregiver working at night. Four out of five staff corroborated insufficient staffing when staff calls out, are on breaks, or when residents require two people to assist. However, Health Service Director Tamara McFadden indicated having sufficient staffing based on the census which was 73 at the time of LPA's initial visit conducted on August 6, 2024. HSD acknowledged assisting caregivers as needed as well as MTs who take double shifts as caregivers. Based on the review of the June 2024 Schedule, on June 16th, 3 caregivers were on schedule during the day, 2 caregivers during the afternoon, and 1 at night. Per the payroll stub on June 16 & 17, 2024, there were at least 3 caregivers for the morning/afternoon shifts and 2 at night. Three caregivers were on duty during the initial visit conducted on August 6, 2024. Six out of the six residents interviewed indicated that their care was not not affected based on the number of staff and expressed receiving good care by the caregivers.

Therefore, due to conflicting information obtained during the investigation, the following allegations, Untrained staff are administering medications and Insufficient staff to meet the residents' needs are deemed unsubstantiated. An exit interview was conducted with Executive Director Eric Jenson, and a copy of this report including the LIC811 were provided at exit.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2025

LIC9099 (FAS) - (06/04)

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