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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331800064
Report Date: 09/02/2021
Date Signed: 09/02/2021 12:48:35 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/02/2020 and conducted by Evaluator Deborah Mullen
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20201002115741
FACILITY NAME:SACRED HEART-STOYVIEWFACILITY NUMBER:
331800064
ADMINISTRATOR:MACIAS, EVELYNFACILITY TYPE:
740
ADDRESS:37189 STOYVIEW CIRCLETELEPHONE:
(951) 698-4258
CITY:MURRIETASTATE: CAZIP CODE:
92563
CAPACITY:6CENSUS: 0DATE:
09/02/2021
UNANNOUNCEDTIME BEGAN:
11:31 AM
MET WITH:Bruce Smerker, LicenseeTIME COMPLETED:
11:40 AM
ALLEGATION(S):
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Residents were transferred to other home without proper notice to authorized representatives

Resident is missing medication

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Deborah Mullen delivered findings of the above allegations. LPA met with Bruce Smerker, Licensee. The Department investigation included interviews with Licensee, staff, and other pertinent witnesses.

Witness interviews revealed 3 residents were transferred to another licensed facility with only 2 days notice to the resident or their authorized representatives. The licensee stated he contacted the responsibly parties for each of the three residents by telephone to let them know the residents were being moved to his other licensed facility. The licensee stated he did not provide a 30-day written notice prior to the transfer, however none of the families objected to the move.


Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021
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 5
Control Number 18-AS-20201002115741
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SACRED HEART-STOYVIEW
FACILITY NUMBER: 331800064
VISIT DATE: 09/02/2021
NARRATIVE
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According to witness interview R1 had medication that was discontinued by the doctor on September 24, 2019. On September 24, 2019 the pill count was 45 pills remaining, however upon discharge from the facility, on September 25, 2020, the remaining pill count was 15. Documentation provided by the facility provided further conflicting evidence in that it showed that on September 19, 2019 the pill count for R1s medication was 45 pills. However, on September 23, 2020 when R1 was discharged from facility documentation showed R1 had 9.5 pills remaining. Interviews were conducted with both the Licensee and the Facility Manager and neither could explain the discrepancy or account for the missing pills.

Based on interviews conducted and a review of facility records, the preponderance of evidence standard has been met and the above allegations that residents were transferred to another home without proper notification and that resident’s medication was missing are substantiated. In accordance with California Code of Regulations, Title 22, citations will be issued as identified on the LIC 9099D. An exit interview was conducted, and a copy of this report was reviewed with and provided to Mr. Smerker.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 18-AS-20201002115741
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SACRED HEART-STOYVIEW
FACILITY NUMBER: 331800064
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/10/2021
Section Cited
CCR
87468.2(a)(20)
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Additional Personal Rights of Residents in Privately Operated Facilities - In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (20) To be protected from involuntary transfers, discharges, and evictions…
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Licensee will review Title 22, Section 87468 and provide a written statement of understanding of the regulation and the intent to abide by said regulation moving forward. POC due to the Department by September 10, 2021.
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This regulation was not being met as evidenced by: Licensee relocated resident from the facility to another one of the Licensees facilities without required notification to resident or resident’s responsible party. This posed a potential health and safety risk to resident in care.
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Type B
09/10/2021
Section Cited
CCR
87465(d)(3)
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Incidental Medical and Dental Care Services: If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.

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Licensee will review Title 22, Section 87465 and provide a written statement of understanding of the regulation and the intent to abide by said regulation moving forward. POC due to the Department by September 10, 2021.
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This regulation was not being met as evidenced by: A review of documentation obtained for R1’s medication count, documented 15 pills missing and unaccounted for. This posed a potential health and safety risk to resident 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: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/02/2020 and conducted by Evaluator Deborah Mullen
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20201002115741

FACILITY NAME:SACRED HEART-STOYVIEWFACILITY NUMBER:
331800064
ADMINISTRATOR:MACIAS, EVELYNFACILITY TYPE:
740
ADDRESS:37189 STOYVIEW CIRCLETELEPHONE:
(951) 698-4258
CITY:MURRIETASTATE: CAZIP CODE:
92563
CAPACITY:6CENSUS: 0DATE:
09/02/2021
UNANNOUNCEDTIME BEGAN:
11:31 AM
MET WITH:Bruce Smerker, LicenseeTIME COMPLETED:
11:40 AM
ALLEGATION(S):
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Staff not trained properly on medication administration
Staff do not have proper training

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Deborah Mullen delivered the findings of the above allegations. LPA met with Bruce Smerker, Licensee. The Department investigation included interviews with Licensee, staff, additional witnesses and a review of facility documentation.

Information reported to the Department was that staff are not trained on how to properly administer medication to residents. The Licensee and Facility Manager both stated staff are provided medication training. Staff 1 (S1) stated she was provided training prior to dispensing medication. Staff 2 (S2) stated she has been employed for a week. S2 stated she has not distributed medication to residents yet as she still requires training on that job function. Information reported by an additional witness providing conflicting information when it was stated that staff are administering medication without proper training.


Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021
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 5
Control Number 18-AS-20201002115741
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SACRED HEART-STOYVIEW
FACILITY NUMBER: 331800064
VISIT DATE: 09/02/2021
NARRATIVE
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The Department received information that staff do not have proper training. The Licensee and Facility Manager both stated staff receive caregiver training prior to working with residents. Both stated caregivers receive training through training videos and job shadowing. The Licensee provided documentation as evidence of training being provided to the caregivers. S1 and S2 both stated they received training on various topics when they were employed. Information reported by an additional witness provided conflicting information when it was stated that staff are not being properly trained on how to care for the residents.

Based on information obtained there is not enough evidence to state staff are not trained on medication administration or that staff do not have proper training. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of this report was reviewed with and provided to Mr. Smerker.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5