306005835-3-20-2024-22-AS-AORZ-D3SUUP-20240328155351

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005835
Report Date: 03/20/2024
Date Signed: 03/20/2024 03:51:26 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
12/28/2023 and conducted by Evaluator Celine DePerio

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20231228123933

FACILITY NAME:	KIRKWOOD ORANGE		FACILITY NUMBER:	306005835
ADMINISTRATOR:	ZEHRA SYED		FACILITY TYPE:	740
ADDRESS:	1525 E TAFT AVENUE		TELEPHONE:	(714) 282-1409
CITY:	ORANGE	STATE: CA	ZIP CODE:	92865
CAPACITY:	66	CENSUS: 45	DATE:	03/20/2024
		UNANNOUNCED	TIME BEGAN:	02:02 PM
MET WITH:	Business Office Manager - Alexis Islas		TIME COMPLETED:	04:16 PM

ALLEGATION(S):

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Facility did not provide medications to residents as prescribed.
Facility did not follow reporting requirements of missed medications to the department.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced visit to the facility to deliver the findings. LPA De Perio explained the purpose of today's visit, was greeted by business office manager (BOM) Alexis Islas.

It was alleged that facility did not provide medications to residents as prescribed. 9 out of 9 resident interviews corroborated with the allegation by confirming that medications were missed. 2 out of 2 staff interviews provided direct admission that medications were missed for a total of 9 residents (R1, R2, R3, R4, R5, R6, R7, R8, R9). Per documentation review of incident reports and the medication administration record, on 12/16/23, R1 missed carbidopa-levo 25-100mg, R2 missed acetaminophen 325mg, R3 missed losartan potassium 100mg and multivitamin tabs, R4 missed acetaminophen 325mg, R5 missed amiodipine besylate 5mg, R6 missed carbidopa-levo 25-100mg, R7 missed sotalol 120mg, R8 missed acetaminophen 325mg, and R9 missed amiodipine besylate 5mg.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024

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-20231228123933

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: KIRKWOOD ORANGE	FACILITY NUMBER: 306005835
	VISIT DATE: 03/20/2024

NARRATIVE

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It was alleged that facility did not follow reporting requirements of missed medications to the department. 9 out of 9 resident interviews were unable to provide additional information regarding this allegation. 2 out of the 2 staff interviews corroborated with the allegation by stating that the executive director present during December 2023, did not report the missed medications to the department due to the facility undergoing changes in management and staffing, which led to the failure of reporting to the department. Per documentation review, a total of 9 residents missed their medications on 12/16/23, and reported it to the department thirteen days later on 12/29/23.

Based on LPA’s interviews which were conducted, review of documents obtained, and observations, the preponderance of evidence standard has been met, therefore the allegations are SUBSTANTIATED.

For this visit, citations were issued.

An exit interview was conducted with BOM Islas.

A copy of this report was explained, and appeal rights were provided during the visit.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 22-AS-20231228123933

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: KIRKWOOD ORANGE	FACILITY NUMBER: 306005835
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/20/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/21/2024 Section Cited CCR 87465(c)(2)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing... (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidence by:	1 2 3 4 5 6 7	As a plan of correction (POC), licensee will provide proof of understanding of the regulation cited to the assigned LPA on or by 3/21/24.
	8 9 10 11 12 13 14	Based on LPA's interviews, review of documents obtained and observations, facility admitted to not giving a total of 9 residents their medications per psychian's directions, and was observed via medication log and incident report that medications were missed in December 2023. This poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
Type B 03/27/2024 Section Cited CCR 87211(a)(1)	1 2 3 4 5 6 7	87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency...within seven days of the occurrence. This requirement is not met as evidence by:	1 2 3 4 5 6 7
	8 9 10 11 12 13 14	Based on LPA's interviews, review of documents obtained and observations, facility failed to report incidents to the licensing department within seven days. Per documentation review, the 9 residents who missed their medications occurred on 12/16/23, but was reported to the department on 12/29/23. This poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14	As a plan of correction (POC), licensee will provide proof of understanding of the regulation cited to the assigned LPA on or by 3/27/24.

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: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024

LIC9099 (FAS) - (06/04)

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