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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006196
Report Date: 01/23/2024
Date Signed: 01/23/2024 01:03:48 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
01/17/2024 and conducted by Evaluator Jessica Cho
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240117112019
FACILITY NAME:GREENTREE GUEST HOMEFACILITY NUMBER:
306006196
ADMINISTRATOR:GARCIA, ANNA CFACILITY TYPE:
735
ADDRESS:12651 GREENTREE AVENUETELEPHONE:
(657) 251-0444
CITY:GARDEN GROVESTATE: CAZIP CODE:
92840
CAPACITY:4CENSUS: 4DATE:
01/23/2024
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Anna Garcia- AdministratorTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff are mismanaging resident's medication.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Jessica Cho and Dwayne Mason arrived unannounced to conduct the complaint investigation into the above allegation. LPAs met with Administrator (Admin) Anna Garcia and stated the purpose of the visit. During the course of the investigation, LPA interviewed staff and reviewed the medications and the Medication Administration Records (MARs). The following was determined:

It is alleged that the staff are mismanaging resident's medication. Per review of four out of the four client medications and MARs, LPAs observed that the prescription medication, Quetiapine, for Client #1 (C1) was ordered to be administered 1/2 tablet in the morning, 1 tablet in the afternoon, and 1/2 tablet every evening. However, LPAs observed via the pillbox and the signatures noted on the MARs that 1 tablet was administered in the evening and the 1/2 tablet at bedtime.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024
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 3
Control Number 22-AS-20240117112019
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: GREENTREE GUEST HOME
FACILITY NUMBER: 306006196
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/31/2024
Section Cited
CCR
80075(b)(6)(B)
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80075 Health Related Service (5) If the client's physician has stated...the licensee shall be permitted to assist the client with self-administration, providing all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions.
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Adminstrator acknowleged to request change of time for when the medication can be administered as long as it is medically safe to do so and to submit proof to LPA via email by POC due date.
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Based on observations, interview, and records reviewed for four out of four clients, C1's medication was not administered at the time required per the doctor's order which poses a potential Health, Safety, or Personal Rights risk to the person 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.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20240117112019
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: GREENTREE GUEST HOME
FACILITY NUMBER: 306006196
VISIT DATE: 01/23/2024
NARRATIVE
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Based on LPAs' observations', interview which was conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegation: Staff are mismanaging resident's medication is deemed SUBSTANTIATED per the California Code of Regulations, Title 22, Division 6, Chapter 1. A citation is being cited on the attached LIC9099D.

An exit interview was conducted with Administrator Anna Garcia, and a copy of this report including the LIC9099C and the LIC811 were provided at the end of the visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3