306005949-5-10-2023-22-AS-MSTC-D2X74P-20240229202015

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005949
Report Date: 05/10/2023
Date Signed: 05/10/2023 02:17:52 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
05/03/2023 and conducted by Evaluator Joseph Alejandre

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230503150639

FACILITY NAME:	CAPISTRANO SENIOR LIVING		FACILITY NUMBER:	306005949
ADMINISTRATOR:	BRYAN HADLEY		FACILITY TYPE:	741
ADDRESS:	31741 RANCHO VIEJO ROAD		TELEPHONE:	(844) 375-0029
CITY:	SAN JUAN CAPISTRANO	STATE: CA	ZIP CODE:	92675
CAPACITY:	125	CENSUS: 97	DATE:	05/10/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Bryan Hadley, Nina Dadabhoy		TIME COMPLETED:	02:40 PM

ALLEGATION(S):

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Facility is mismanaging resident's medication.

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 investigation into the allegation listed above. LPA met with Executive Director Bryan Hadley and Health and Wellness Director Nina Dadabhoy and explained the reason for the visit. The investigation into the allegation, facility is mismanaging resident's medication revealed the following. Resident 1 (R1) moved into the facility from a skilled nursing facility (SNF) on 4/21/23. It was reported that R1 had 7 medications which were transferred with R1 to the new facility. A review of records shows R1’s medication order summary dated 4/22/23 lists 12 medications, 4 of which are not active. The medication administration record (MAR) for April 2023 lists 7 medications with all prescriptions starting on 4/27/23. Staff reported that when R1 arrived at the facility they contacted the doctor and the pharmacy to refill R1’s prescriptions. Staff reported that attempts to contact R1’s physician were unsuccessful and the pharmacy reported they could not refill the prescriptions without authorization from R1’s physician. This report from staff cannot be verified. A review of facility documents shows staff Faxed the pharmacy on 4/26/23 and the doctor on 5/2/23.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph Alejandre	TELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023

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-20230503150639

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: 05/10/2023

NARRATIVE

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Staff reported that when R1 arrived at the facility they received medication from the SNF and continued to administer the medication until it was refilled on 4/27/23. Witnesses interviewed reported that medication for R1 was delivered to the facility by a family member on 5/1/23. Witnesses interviewed reported that R1 did not receive any medication from 4/22/23 until 5/1/23 except for Levothyroxine Sodium 137 MCG tablets. Witnesses and staff report conflicting information concerning the administration of R1’s medication. LPA conducted an audit of R1’s medication for May 2023 with staff present, which included a review of the MAR for May 2023, no discrepancies were observed. A review of the MAR for April 2023 for R1 shows that R1 received 7 medications daily from 4/27/23 to 4/29/23 and no medications administered from 4/22/23 to 4/26/23 and 4/30/23. Staff reported that the medications from the SNF were administered but not listed on the MAR for April 2023. Based on the evidence gathered through interviews and a review of records the preponderance of evidence standard has been met, therefore the allegation, facility is mismanaging resident's medication is found to be Substantiated. Violations are being cited per California Code of Regulations Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report along with citation and Appeal Rights (LC 9058 3/22) was provided.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph Alejandre	TELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 22-AS-20230503150639

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: 05/10/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/11/2023 Section Cited CCR 87465(c)(2)	1 2 3 4 5 6 7	Incidental Medical and Dental Care. Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee to ensure all medications are given in accordance to doctor's orders at all times by training medication technician staff on CCR 87465, Incidental Medical and Dental Care. Licensee to provide proof of training to LPA POC due date.
	8 9 10 11 12 13 14	based on a review of records R1 was not administered any medications from 4/22/23 to 4/26/23 and on 4/30/23. This poses an immediate risk to the health & safety of residents 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: Luz Adams	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph Alejandre	TELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3