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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005511
Report Date: 11/05/2020
Date Signed: 11/05/2020 12:32:10 PM



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
02/11/2020 and conducted by Evaluator Ruth Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20200211170957
FACILITY NAME:MILESTONE ELDER CAREFACILITY NUMBER:
306005511
ADMINISTRATOR:KONTAR, JOHNFACILITY TYPE:
740
ADDRESS:25142 LAS BOLSASTELEPHONE:
(949) 742-0247
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY:6CENSUS: 4DATE:
11/05/2020
UNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:John KontarTIME COMPLETED:
12:20 PM
ALLEGATION(S):
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• Personal Rights Violation
• Facility Staff are not dispensing resident’s medication as prescribed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ruth Martinez contacted the facility via tele-visit due to COVID-19 precautionary measures to deliver findings for the investigation into the above identified complaint allegations. LPA spoke with John Kontar, Administrator and explained the purpose of the telephone call.

During the course of the investigation LPA interviewed residents and staff, toured the physical plant of the facility, reviewed 4 out of 4 residents’ records. Only 2 residents had prescribed medication and LPA reviewed their medication.

It is alleged that residents’ rights are being violated by Administrator and caregiver who argue, scream at each other and use profanity in front of the residents. During the visit conducted on 02/12/2020 while discussing the allegations with Staff 1 (S1) and Staff 2 (S2), LPA witnessed S1 and S2 arguing back and forth. The tone of their

Continued on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2020
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 5
Control Number 22-AS-20200211170957
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: MILESTONE ELDER CARE
FACILITY NUMBER: 306005511
VISIT DATE: 11/05/2020
NARRATIVE
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voices was extremely elevated as to which LPA had to ask both parties to stop yelling and lower their tone of voice. Upon conducting interviews with residents LPA was able to hear S1 and S2 to continue arguing and using profanity at an elevated tone of voice by both individuals. Interview with Resident 1 (R1) revealed that R1 had recordings of past arguments by S1 and S2. R1 indicated that recordings were done while bedroom door was closed. R1 allowed LPA to hear the recordings and was able to hear clearly S1 and S2 arguing at a very loud tone of voice.

It is alleged that facility staff are not dispensing resident’s medication as prescribed. On 02/12/2020 LPA upon arrival to the facility observed a measuring medication cup with two pills in it, a pink and yellow on the kitchen table unattended. Upon review of R1’s medications a bubble pack for Mirtazapine 15 mg tablet showed a yellow pill remaining in spaces 12-16, bubble pack #1 and #2 of 6 for Flecainide Acetate 50 mg tablet showed a white pill remaining in spaces 13-16, bubble pack # 5 of 6 shows a white pill with only space 18 punched out, bubble pack for Aspirin 81 mg chewable tablet shows a light pink pill remaining in spaces 13-16, and bubble pack for Atrovastatin 10 mg tablet shows a yellow pill remaining in spaces 13-16. This would indicate that medication was not dispensed as prescribed for R1. Facility staff was unable to provide any documentation that would show that medication was dispensed as prescribed. Based on the LPAs observations of medication not dispensed and lack of any documentation that would record medication dosage given the above allegation is substantiated.

During the course of the investigation, there was sufficient evidence to substantiate the allegations mentioned above. The preponderance of evidence standard has been met; therefore, the above allegations are substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with Administrator via tele-visit a copy of the report along with appeal rights was sent via email and an electronic email read receipt confirms receiving of the report. Administrator agrees to review, agrees to send the signed report via email.
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 22-AS-20200211170957
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: MILESTONE ELDER CARE
FACILITY NUMBER: 306005511
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/05/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/19/2020
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. This regulation was not met as evidence by: During review of medication for R1, LPA observed medication cup with two pills a pink/yellow on the kitchen table unattended. Upon review of resident medication for R1
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Licensee will ensure that once ordered by the physician the medication is given according to the physician's directions. Licensee to submit written plan to CCL outlining how the facility will ensure medication will be dispensed as prescribed.
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Mirtazapine shows a pill in #12-16, Flecainide Acetate shows a pill in #13-16, pack 5 of 6 shows a pill with only #18 punched out, Aspirin shows a pill in #13-16, and Atrovastatin shows a pill in #13-16. This would indicate that medication is not being dispensed as prescribed. This poses an immediate risk to residents in care.
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 Licensee to provide training to all staff on section cited by POC due date. Licensee will provide in-service training to all staff on cited section. Provide proof of scheduled in-service training and copies of attendance sign in sheet of training to LPA by POC due date.
Type B
11/19/2020
Section Cited
CCR
87468.1(a)(1)
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Personal Rights: Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity...This requirement is not being met as evidenced by: Based on observation and interviews, Licensee did not ensure residents are afforded dignity in the facility. While LPA discussed the allegations with S1 and S2,
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 Licensee to provide training to all staff on section cited by POC due date. Licensee will provide in-service training to all staff on cited section. Provide proof of scheduled in-service training and copies of attendance sign in sheet of training to LPA by POC due date.
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LPA observed S1 and S2 arguing back and forth. The tone of their voices was extremely elevated. Upon conducting interviews with residents LPA was able to hear S1 and S2 arguing and using profanity at an elevated tone of voice by both individuals. This poses a potential health and safety risk to residents in care.
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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.
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
02/11/2020 and conducted by Evaluator Ruth Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20200211170957

FACILITY NAME:MILESTONE ELDER CAREFACILITY NUMBER:
306005511
ADMINISTRATOR:KONTAR, JOHNFACILITY TYPE:
740
ADDRESS:25142 LAS BOLSASTELEPHONE:
(949) 742-0247
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY:6CENSUS: DATE:
11/05/2020
UNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:John KontarTIME COMPLETED:
12:20 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
• Staff did not provide clean and sanitary environment
INVESTIGATION FINDINGS:
1
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5
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Licensing Program Analyst (LPA) Ruth Martinez contacted the facility via tele-visit due to COVID-19 precautionary measures to deliver findings for the investigation into the above identified complaint allegations. LPA spoke with John Kontar, Administrator and explained the purpose of the telephone call.

During the course of the investigation LPA interviewed residents and staff, toured the physical plant of the facility, reviewed 4 out of 4 residents’ records.

It is alleged that staff did not provide clean and sanitary environment. On 02/12/2020 inspection LPA conducted a tour of the physical plant of the facility and observed facility to be clean and free of debris and odors. LPA did not notice any foul odors, stains or unsanitary conditions in restrooms, kitchen, bedrooms or common areas of facility. Interviews with R1 revealed that R2 wears diapers and at times R2 had accidents and would take off the

Continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20200211170957
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: MILESTONE ELDER CARE
FACILITY NUMBER: 306005511
VISIT DATE: 11/05/2020
NARRATIVE
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diaper and the walkway to the restroom would be dirty. However, R1 stated that caregiver would clean up the hallways and bathroom after R2 once caregiver was able to finish changing and attending to R2’s needs.

Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the allegation occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated.

An exit interview was conducted with Administrator via tele-visit a copy of the report was sent via email and an electronic email read receipt confirms receiving of the report. Administrator agrees to review, agrees to send the signed report via email.
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2020
LIC9099 (FAS) - (06/04)
Page: 5 of 5