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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005949
Report Date: 10/28/2022
Date Signed: 10/28/2022 01:08:13 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
10/20/2022 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20221020121537
FACILITY NAME:CAPISTRANO SENIOR LIVINGFACILITY NUMBER:
306005949
ADMINISTRATOR:BRYAN HADLEYFACILITY TYPE:
741
ADDRESS:31741 RANCHO VIEJO ROADTELEPHONE:
(844) 375-0029
CITY:SAN JUAN CAPISTRANOSTATE: CAZIP CODE:
92675
CAPACITY:125CENSUS: 93DATE:
10/28/2022
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Bryan HadleyTIME COMPLETED:
01:25 PM
ALLEGATION(S):
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Unqualified staff administer injections to residents in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required 10-day visit to begin the complaint investigation into the allegation listed above. LPA was greeted and granted entry by staff. LPA met with Executive Director Bryan Hadley. LPA explained the reason for the visit. LPA interviewed residents and staff in assisted living area and the memory care unit. LPA obtained and reviewed facility and resident records. The investigation into the allegation, unqualified staff administer injections to residents in care, revealed the following; The facility has residents that are diabetic. California Code of Regulations (CCR, Title 22, Division 6) 87628(a) states; The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional. LPA verified that staff who administer medication at the facility are not licensed nurses. Residents reported that staff at the facility have performed the glucose testing on residents with a lancet. Staff verified this report. Residents reported that staff have administered insulin injections without the aid of residents.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2022
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-20221020121537
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: CAPISTRANO SENIOR LIVING
FACILITY NUMBER: 306005949
VISIT DATE: 10/28/2022
NARRATIVE
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Staff reported that they use the hand over hand technique to administer insulin injections. Staff reported they have used the hand over hand technique with residents in memory care to administer insulin injections. Memory care residents could not verify this information. Based on the evidence gathered through interviews and a review of records the preponderance of evidence standard has been met, therefore the allegation, unqualified staff administer injections to residents in care, is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report was provided to facility administrator along with appeal rights.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20221020121537
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: CAPISTRANO SENIOR LIVING
FACILITY NUMBER: 306005949
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/29/2022
Section Cited
CCR
87628(a)
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Diabetes-The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional. This requirement,
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Licensee will ensure all residents with diabetes will have their blood sugar levels tested by a skilled professional if a resident cannot conduct their own testing and will have all injections for diabetic residents administered by a skilled professional if the resident cannot administer their own injection. Proof to be submitted to LPA by POC due date.
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is not being met as evidenced by, evidence gathered in interviews revealed that staff (non-licensed) administer prescribed medication (insulin) through injections and perform glucose testing via lancet on residents without assistance. This poses an immediate 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: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3