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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005462
Report Date: 10/21/2022
Date Signed: 10/21/2022 04:49:05 PM

Substantiated


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
09/11/2020 and conducted by Evaluator Shobhana Frank
COMPLAINT CONTROL NUMBER: 22-AS-20200911142152
FACILITY NAME:EASTERSEALS SOUTHERN CALIFORNIA-CLARISSA RESIDENCEFACILITY NUMBER:
306005462
ADMINISTRATOR:ARMANDO FLORESFACILITY TYPE:
735
ADDRESS:14361 CLARISSA LANETELEPHONE:
(714) 526-4079
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY:4CENSUS: 2DATE:
10/21/2022
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Administrator Armando FloresTIME COMPLETED:
10:55 AM
ALLEGATION(S):
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Client not given medication as prescribed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Shobhana Frank made an unannounced complaint visit to deliver findings on the above allegations. LPA was greeted and granted entry by Administrator (AD) Armando Flores and explained the reason for the visit.
During the course of investigation LPA Shobhana Frank conducted interview at facility with RP, Staff 1 (S1) and reviews Medication Administration Record(MAR) dated 8/2020, Doctor’s Order7/21/2020,Staff Training log, dated11/2020, LIC 500 Personnel Report, Special incident Report dated 8/25/2020.
Based on Interviews of S 1 and review of Medication Administration Record(MAR) dated 8/2020, Doctor’s Order7/21/2020 Lamictal was to be increased from 250 mg to 300 mg doses. When new medication Lamictal arrived facility staff didn't checked the medication. Pharmacy didn't followed doctor's order and send Lamictal 550 mg instated of 300 mg. Facility has already conducted new training and implemented medication training, renew procedure. Based on LPA's observations and conducted interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Shobhana Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 22-AS-20200911142152
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: EASTERSEALS SOUTHERN CALIFORNIA-CLARISSA RESIDENCE
FACILITY NUMBER: 306005462
VISIT DATE: 10/21/2022
NARRATIVE
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The following deficiency is a violation of Title 22, Division 6, of the California Code of Regulations. meaning that although the allegation may have happened or are valid, there is a preponderance of the evidence prove that the alleged violation occurred.

An exit interview was conducted with Administrator and a copy of this report was provided.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Shobhana Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20200911142152
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: EASTERSEALS SOUTHERN CALIFORNIA-CLARISSA RESIDENCE
FACILITY NUMBER: 306005462
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/28/2022
Section Cited
CCR
87465(C)(2)
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Incidental Medical and Dental Care.Once ordered by the physician the medication is given according to the physician's directions.Based on interview of Administrator who admitted that he caught the error, Client not given medication as prescribed
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CORRECTED. Facility implemented a new training form to cycle the medication. A copy of training was provided.
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which poses an immediate health risk to residents in car.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Shobhana Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3