306005773-9-29-2023-22-AS-AORZ-CWKLYP-20231013091037

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005773
Report Date: 09/29/2023
Date Signed: 09/29/2023 12:53:14 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
09/22/2023 and conducted by Evaluator Alvaro Ramirez Jr.

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230922105610

FACILITY NAME:	FAMILY CHOICE SENIOR LIVING		FACILITY NUMBER:	306005773
ADMINISTRATOR:	JUNGE, PAMELA		FACILITY TYPE:	740
ADDRESS:	3105 W. ORANGE STREET		TELEPHONE:	(714) 229-0069
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92804
CAPACITY:	30	CENSUS: 12	DATE:	09/29/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Enedelia Sigala-Caregiver, Pamela Junge-Administrator		TIME COMPLETED:	01:08 PM

ALLEGATION(S):

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Staff are falsifying the MAR

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced initial 10-Day complaint visit to initiate the investigation into the above allegation and to deliver the findings of the investigation. LPA was greeted and granted entry into the facility and met with Caregiver Enedelia Sigala. LPA explained the reason for the visit. Administrator (AD) Pamela Junge arrived shortly after.

This agency has investigated the complaint alleging that staff are falsifying the Medication Administration Record (MAR). LPA Ramirez conducted file reviews and interviews and obtained copies of pertinent documents. Regarding the allegation, the following was revealed: During the investigation LPA reviewed documents including the Physician Report (LIC602A) dated 09/22/22 for Resident 1 (R1). Per Physician Report R1 is not able to administer own prescription medications. Records reviewed by LPA Ramirez included the Medication Administration Record (MAR) dated September 2023 for R1.

Continued on LIC9099-C...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

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-20230922105610

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: FAMILY CHOICE SENIOR LIVING	FACILITY NUMBER: 306005773
	VISIT DATE: 09/29/2023

NARRATIVE

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Per MAR for R1 on 09/14/23 the evening medications Donepezil HCL 10mg and Olanzapine 10 mg were not logged in and/or initial by the assigned Medication Technician (MT). During the course of the interviews AD stated that she does her best at auditing the MAR but that the assigned MT forgot to log it in. Per MAR for R2 the morning medication Oxybutynin Chloride 5 mg has only been logged in eight times in the past twenty- nine days. Per MAR R2 should take two tablets by mouth daily. Per AD she is waiting on the Primary Care Physician (PCP) from Kaiser to prescribed a refill for R2's medication.

Based on the interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegation: staff are falsifying the MAR is deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 is being cited on the attached LIC 9099D.

An exit interview was conducted with AD Junge and a copy of this report along with the Appeal Rights were provided at the time of this visit.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20230922105610

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: FAMILY CHOICE SENIOR LIVING	FACILITY NUMBER: 306005773
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/29/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/02/2023 Section Cited CCR 87465(c)(2)	1 2 3 4 5 6 7	Incidental Medical and Dental Care (c)If the resident's physician has stated in writing...facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication	1 2 3 4 5 6 7	Administrator stated that an in-house training on passing medication as ordered by the physician will be conducted. Licensee to submit written proof to LPA by POC due date.
	8 9 10 11 12 13 14	is given according to the physician's directions. This requirement is not met as evidence by: Per LPAs observations and interviews conducted the Medication Administration Record for R1 and R2 are not fill out completely. This poses an immediate health and safety risk to clients in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

LIC9099 (FAS) - (06/04)

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