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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 312700158
Report Date: 05/27/2021
Date Signed: 05/27/2021 07:00:24 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/26/2020 and conducted by Evaluator Michael Reber
COMPLAINT CONTROL NUMBER: 27-AS-20200326075449
FACILITY NAME:OLYMPUS RIDGE RCFEFACILITY NUMBER:
312700158
ADMINISTRATOR:PAVLOVIC, NEVENKA GFACILITY TYPE:
740
ADDRESS:248 SKOPAS CTTELEPHONE:
(916) 540-7159
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:6CENSUS: 6DATE:
05/27/2021
UNANNOUNCEDTIME BEGAN:
05:45 PM
MET WITH:Cindy Fisher, CaregiverTIME COMPLETED:
07:15 PM
ALLEGATION(S):
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 - Facility staff mismanaged resident's medication.
- Staff not administering resident's medication as prescribed
INVESTIGATION FINDINGS:
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Analyst Mike Reber arrived at the facility today, 5/27/21, and met with caregiver, Cindy Fisher, to deliver investigation findings to the above stated allegations. During the course of the investigation, this analyst conducted interviews and obtained/reviewed documentation pertinent to the investigation.

Upon entering the facility, analyst spoke with staff to pre-screen that the facility is COVID free. Analyst also self-screened for having no known symptoms or exposure. Analyst followed facility's screening, wore an N-95 respirator and maintained distance during the visit.


**********************************Report continued on LIC 9099C********************************

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alycia BerrymanTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Michael ReberTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2021
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 4
Control Number 27-AS-20200326075449
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: OLYMPUS RIDGE RCFE
FACILITY NUMBER: 312700158
VISIT DATE: 05/27/2021
NARRATIVE
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Facility staff mismanaged resident's medication.
Documents obtained indicates that resident (R1) arrived at the facility on 3/23/20. Interviews with the licensee and live-in caregiver, revealed that R1 arrived on an ambulance and that R1 did not arrive with all medications and doctor's orders. On 3/30/20, the licensee stated in an interview with a Licensing Program Analyst that it took three days before she was able to secure all doctors orders and medications for R1. The licensee stated to this analyst on 4/26/20 that she was able to get doctor's orders and resident medications by the next day. Licensee should not have accepted R1 without verifying that all medications had been secured at admission to ensure that the facility could meet the residents medication needs.

Staff not administering resident's medication as prescribed
In an interview with the licensee on 3/30/20, the licensee states that when the resident was admitted to the facility, "they were only given 2 out of 10 medications that the resident was prescribed" R1 was also prescribed the drug, Coumadin, and the licensee did not administer the medication because the licensee failed to obtain updated lab work that is required to administer the medication.

Based on interviews conducted and records reviewed, this analyst finds the above stated allegation to be SUBSTANTIATED - a finding that means that the allegation is valid because the preponderance of the evidence standard has been met.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D.

Exit interview conducted. Copy of report and appeal rights provided to staff.

Signature obtained on hard copy of report and placed in facility file

SUPERVISOR'S NAME: Alycia BerrymanTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Michael ReberTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20200326075449
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: OLYMPUS RIDGE RCFE
FACILITY NUMBER: 312700158
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/07/2021
Section Cited
HSC
1569.2(c)
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"Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with taking medications, money management, or personal care.
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R1 is currently is receiving all medications prescribed by her physician and is no longer at immediate risk. The licensee shall submit a statement of understanding of this regulation to LPA by POC due date of 6/7/21.
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Based on documents recieved and interviews conducted this requirement has not been met by not ensuring that all medications had been secured when admitting R1 to the facility. This poses an immediate threat to the resident in care.
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Type A
06/07/2021
Section Cited
CCR
87465(a)(5)
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Incidental Medical and Dental Care - (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (5)The licensee shall assist residents with self-administered medications as needed.
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R1 is currently is receiving all medications prescribed by her physician and is no longer at immediate risk. The licensee shall submit a statement of understanding of this regulation to LPA by POC due date of 6/7/21.
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Based on documents recieved interviews conducted, this requirement has not been met due to resident only receiving "2 out of 10" medications upon admission to the facility.
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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: Alycia BerrymanTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Michael ReberTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/26/2020 and conducted by Evaluator Michael Reber
COMPLAINT CONTROL NUMBER: 27-AS-20200326075449

FACILITY NAME:OLYMPUS RIDGE RCFEFACILITY NUMBER:
312700158
ADMINISTRATOR:PAVLOVIC, NEVENKA GFACILITY TYPE:
740
ADDRESS:248 SKOPAS CTTELEPHONE:
(916) 540-7159
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:6CENSUS: 6DATE:
05/27/2021
UNANNOUNCEDTIME BEGAN:
05:45 PM
MET WITH:Cindy Fisher, CaregiverTIME COMPLETED:
07:15 PM
ALLEGATION(S):
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Facility staff are not properly trained.
INVESTIGATION FINDINGS:
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Analyst reviewed staff medication training records for live-in staff (S1). Records indicate that S1 received required medication training in March of 2019 and received another 4 hours of annual medication training on 8/1/2020. Documents obtained and Interviews conducted indicate that much of the confusion around the residents medication stemmed from R1 arriving at the facility from her previous placement without all medications and physician's orders in place. Analyst is unable to determine that a lack of training by staff contributed to issues with resident medications.

Based on information obtained, Analyst finds the allegations to be UNSUBSTANTIATED - a finding meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

As a result of this investigation, no deficiencies were cited, per Title 22 Regulations, Division 6.
Exit interview conducted. Copy of report left with staff. Signature obtained on hard copy of report and placed in facility file.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alycia BerrymanTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Michael ReberTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4