306005275-3-4-2024-22-AS-SSAS-D36QUM-20240308112855

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005275
Report Date: 03/04/2024
Date Signed: 03/04/2024 04:28:31 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
02/27/2024 and conducted by Evaluator Kevin Saborit-Guasch

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20240227141035

FACILITY NAME:	MERRILL GARDENS AT HUNTINGTON BEACH		FACILITY NUMBER:	306005275
ADMINISTRATOR:	JOHNSON, JILL		FACILITY TYPE:	740
ADDRESS:	17200 GOLDENWEST ST		TELEPHONE:	(714) 842-6569
CITY:	HUNTINGTON BEACH	STATE: CA	ZIP CODE:	92647
CAPACITY:	150	CENSUS: 121	DATE:	03/04/2024
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Jill Johnson, General Manager		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

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Staff mishandled a resident's medication while in care

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 conducting the initial investigation into the allegation listed above. LPA was greeted and granted entry by facility administrator Jill Johnson after introducing himself and stating the allegation investigated.

LPA requested and obtained the facility's current resident census as well as resident records for three facility residents, including the residents' facesheet, physician reports and prescription orders and medication administration records for the month of February, when applicable. LPA additionally conducted two staff interviews, one witness interview and one resident interview.

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: 03/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2024

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-20240227141035

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: MERRILL GARDENS AT HUNTINGTON BEACH	FACILITY NUMBER: 306005275
	VISIT DATE: 03/04/2024

NARRATIVE

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CONTINUED FROM FORM LIC9099

Regarding the allegation that Staff mishandled a resident's medication while in care, the following has been concluded: Interviews and review of records confirmed that resident R1 was unable to receive the medication Tolvaptan as prescribed by their primary care physician on one instance on February 24, 2024 after the facility exhausted their current supply of the medication. However, interviews with facility staff evidenced that the medication had been identified to require a refill as early as February 5, 2024. Facility medication staff reached out to the pharmacy in charge of filling the medication orders for R1 at that time and were informed that the refill was pending approval from the resident's health insurance provider. Per the medication staff communication log, additional follow-up calls were placed on February 7, February 12, February 20 and February 24 as well as on February 27, 2024. There are documented instances of such pre-approvals being granted by insurance in the past, however in that instance the pre-authorization was alleged declined and is currently pending appeal to the insurance provider. In the meantime, due to the reported prohibitive cost of the medication, R1 has been provided with samples provided by the primary care provider in order to maintain the prescribed dispensation schedule and avoid any adverse effects. A review of the medication administration records and multiple interviews confirmed that R1 has since been receiving every dose as prescribed.

Based on the evidence gathered, it cannot be determined that the missed medication dose was the result of a negligence from facility staff, therefore 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 or refute 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: 03/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2024

LIC9099 (FAS) - (06/04)

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