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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006132
Report Date: 03/08/2024
Date Signed: 03/08/2024 02:58:16 PM

Unsubstantiated


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
02/22/2024 and conducted by Evaluator Kevin Saborit-Guasch
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240222144958
FACILITY NAME:BEVERLY HOMEFACILITY NUMBER:
306006132
ADMINISTRATOR:CHEA, PAULFACILITY TYPE:
735
ADDRESS:1183 W. CHATEAU AVETELEPHONE:
(714) 215-4396
CITY:ANAHEIMSTATE: CAZIP CODE:
92802
CAPACITY:6CENSUS: 3DATE:
03/08/2024
UNANNOUNCEDTIME BEGAN:
02:01 PM
MET WITH:Paul Chea, Administrator (via phone)TIME COMPLETED:
03:15 PM
ALLEGATION(S):
1
2
3
4
5
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7
8
9
Facility did not ensure client was assisted with self administration of prescription medication
INVESTIGATION FINDINGS:
1
2
3
4
5
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7
8
9
10
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13
On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of delivering findings in the investigation of the allegation listed above. LPA was greeted and granted entry after stating the purpose of the visit. Facility administrator was notified of the visit via telephone and was presented with the findings remotely. Administrator agreed to have caregiving staff sign the report on his behalf.

An initial compaint investigation visit was conducted on February 27, 2024. LPA requested, obtained and reviewed facility medication administration records for all three current clients in addition to their respective identification forms and physician orders. The content of the medication cabinet and the secure medication central storage were also observed during the visit.

Additional witness interviews were conducted by phone following the initial visit.
CONTINUED ON FORM LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024
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 2
Control Number 22-AS-20240222144958
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: BEVERLY HOME
FACILITY NUMBER: 306006132
VISIT DATE: 03/08/2024
NARRATIVE
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CONTINUED FROM FORM LIC9099
Regarding the allegation that Facility did not ensure client was assisted with self administration of prescription medication, the following has been concluded: Client C1 was hospitalized on February 16, 2024 to address a persistent cough with inability to expel phlegm which also impacted the client's ability to swallow medications upon self-administration. The client was diagnosed with pneumonia along excessive sodium levels/hypernatremia at the hospital which facility staff believes may have been a side-effect of the lithium carbonate prescribed. Facility staff interviews and observation conducted at the facility confirmed that the medication was being dispensed as prescribed. Additional witness interviews conducted denied any suspicion of neglect on the part of facility staff.

As a result, the allegation is found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred.

An exit interview was conducted and a copy of this report was provided to a facility representative.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2