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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005554
Report Date: 05/02/2025
Date Signed: 05/02/2025 04:42:05 PM

Substantiated


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
04/25/2025 and conducted by Evaluator Jessica Cho
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250425145035
FACILITY NAME:DEVOTED HEART CARE HOMES LLCFACILITY NUMBER:
306005554
ADMINISTRATOR:KEVIN CLARKFACILITY TYPE:
735
ADDRESS:26665 AVENIDA SHONTOTELEPHONE:
(818) 384-9331
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:4CENSUS: 3DATE:
05/02/2025
UNANNOUNCEDTIME BEGAN:
07:15 AM
MET WITH:Laura Palomino- AdministratorTIME COMPLETED:
04:41 PM
ALLEGATION(S):
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Facility did not administer medication as prescribed.

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jessica Cho arrived unannounced for the purpose of conducting the complaint investigation into the above allegation. LPA met with Administrator (Admin) Laura Palomino and explained the reason for the visit.

During the course of the investigation, LPA interviewed three clients and three staff and obtained records which includes the Client Roster, Personnel Report Summary, Face Sheets, Physician's Reports, Admission Agreement, Individual Program Plans, Quarterly Behavioral Report, Medication Administration Records (MARs), and other pertinent documentation. Additionally, LPA conducted a review of two out of three client medications for April/May 2025. The third client is not prescribed with any medications.

Regarding the allegation, Facility did not administer medication as prescribed, it was alleged that Quetiapine Fumarate 50 mg was given too many times.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2025
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-20250425145035
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: DEVOTED HEART CARE HOMES LLC
FACILITY NUMBER: 306005554
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/23/2025
Section Cited
CCR
80075(b)(5)(B)
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80075 Health Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (B) Once ordered by the physician the medication is given according to the physician's directions.

This requirement was not met as evidenced by:
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Administrator stated that the incident report for the medication errors, proof of reconciliation of C1's MAR for May, proof of staff medication training, and a schedule and duties of persons reconciling will be sumbitted to LPA via email by POC due date.
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Based on observation, interviews, and record review, nine medications were not administered as prescribed which poses a potential Health, Safety, and/or Personal Rights risk to persons 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.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 22-AS-20250425145035
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: DEVOTED HEART CARE HOMES LLC
FACILITY NUMBER: 306005554
VISIT DATE: 05/02/2025
NARRATIVE
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Per Client #1 (C1)'s MAR for April 2025, Quetiapine is intended to be given by mouth every 6-8 hours as needed and should not exceed 4 tablets within 24 hours. Based on the review, it appears that C1 was given at most three times day, in the morning, noon, and bedtime. The second dose if needed was intended to be administered at least six hours after the first dose in the morning, however the dosing interval was inadequately spaced. Other medications that were not administered the entire month of April 2025 includes, Mucus Relief ER 600 mg tablet and on May 1st, Multivitamin tablet, Certrizine HCL 10 mg tablet also in May 1st, Eye Itch Relief 0.025% drops, Fluticasone Drop 50 MCG Spray was only applied for two days out of the month, and FT Allergy Relief 3-24 hour tablet. For the month of May 2025, Polyethylene Glycol, and Vyvance 20 MG Capsule were also not administered. Three out of the three staff interviewed acknowledged the errors after the audit and one out of three clients did not corroborate the allegation. Interviews with the remaining two clients were unsuccessful.

Therefore, based on observation, interviews, and record review, the preponderance of evidence standard has been met, therefore the following allegation, Facility did not administer medication as prescribed is deemed SUBSTANTIATED as per the Title 22 California Code of Regulations. Refer to the attached LIC9099D.

An exit interview was conducted with Administrator Laura Palomino, and a copy of this report including the LIC811, and the appeal rights were provided at exit.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5