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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331800484
Report Date: 11/08/2022
Date Signed: 11/08/2022 10:46:48 AM

Substantiated


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
09/02/2021 and conducted by Evaluator Crystal Colvin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210902121126
FACILITY NAME:VIA GENOAFACILITY NUMBER:
331800484
ADMINISTRATOR:EDGINGTON, JOHN TFACILITY TYPE:
735
ADDRESS:47018 VIA GENOATELEPHONE:
(760) 262-5957
CITY:INDIOSTATE: CAZIP CODE:
92201
CAPACITY:4CENSUS: 4DATE:
11/08/2022
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Paulina Corona - House ManagerTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Facility is inadequately staffed

Facility staff gave resident the wrong prescribed medication, causing an allergic reaction
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Crystal Colvin and Janira Arreola arrived at the facility unanounced in order to deliver findings of a complaint with the above allegation(s). LPA identified herself and discussed the purpose of the visit with House Manager Paulina Corona. Below is a summary of the findings:

Regarding allegation "Facility is inadequately staffed": LPA Colvin conducted interviews and reviewed pertinent facility documents, including staff schedule and residents’ Inland Regional Center (IRC) Individual Program Plans (IPP). LPA Colvin observed that at least two of the four residents present at the facility during the investigation (R1 & R2) require 1:1 supervision during waking hours. In contrast to this, LPA Colvin confirmed through interviews conducted that the facility regularly has only two or three staff present during shifts, especially in afternoon/pm shift. LPA Colvin additionally observed that the facility has a staff schedule that separates staffing for the facility as a whole and staffing for residents who require 1:1 supervision. LPA Colvin observed that despite both R1 & R2’s IPPs stating that they need 1:1 during the daytime, frequently only either R1 or R2 have 1:1 during the daytime, almost never both residents.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2022
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 7
Control Number 18-AS-20210902121126
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: VIA GENOA
FACILITY NUMBER: 331800484
VISIT DATE: 11/08/2022
NARRATIVE
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Additionally, there a multiple days and shifts (both AM and PM) where no staff are scheduled for 1:1 for either resident. R1 is approved for 15 hours of 1:1 supervision during waking hours due to R1’s disruptive behavior (IPP dated 9/23/19) and R2 is approved for up to 16 hours of 1:1 supervision during waking hours due to “severe behaviors” (IPP dated 10/15/19). Therefore, based on interviews and record review, the allegation “Facility is inadequately staffed.” Is SUBSTANTIATED.

Regarding allegation "Facility staff gave resident the wrong prescribed medication, causing an allergic reaction": LPA Colvin conducted interviews with staff as well as reviewed facility records for R1. LPA Colvin observed a Special Incident Report (SIR) dated 11/20/20, wherein it was reported that a staff member (S1) accidentally administered the wrong medication to R1 during AM medication pass. According to the SIR, one of the medications accidentally administered to R1 (Olanzapine) is a medication that R1 is allergic to. R1’s responsible parties were notified and 911 was called and R1 was admitted to the ER for observation. The SIR additionally stated that prior to calling 911, staff observed R1 to be “off his baseline” and R1’s responsible parties stated that in the past, when R1 has taken this medication R1 has become delirious and unable to walk. Additional staff interviews conducted by LPA Colvin revealed that R1 was “extremely groggy” and “super sleepy” and a staff member was sent to the ER to watch R1. Therefore, due to record review and interviews conducted, the allegation “Facility staff gave resident the wrong prescribed medication, causing an allergic reaction.” Is SUBSTANTIATED.

A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met.

Due to observations made by LPA Colvin, the facility was cited and deficiencies noted on LIC 9099 D. An exit interview was conducted where this report and appeal rights were discussed. A copy this report, LIC 9099D, and appeal rights were provided to House Manager Paulina Corona during the exit interview.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 7
Control Number 18-AS-20210902121126
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: VIA GENOA
FACILITY NUMBER: 331800484
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/09/2022
Section Cited
CCR
85066(b)
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Personnel Requirements: (b) The licensee shall employ staff as necessary to ensure provision of care and supervision to meet client needs. This requirement was not met as evidenced by:
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Licensee agrees to evaluate current reidents' staffing ratio needs (as identified in IPPs) and hire additional staff or employ staffing agencies as needed. Licensee to provide LPA Colvin with analysis of current staff and current residents' staffing ratio needs, if facility is meeting that need, and if not, what the Licensee
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Based on record review and interview, the Licensee did not comply with the above regulation with 2 residents. R1 & R2 both require 1:1 supervision due to their behaviors, but the facility schedule reflects that rareely are R1 & R2 both provided a 1:1 staff member. This was an immedaite safety risk for R1 & R2.
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plans to do in order to meet that need.
Type A
11/09/2022
Section Cited
CCR
80087(a)
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Responsibility for Providing Care and Supervision: (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement was not met as evidenced by:
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Licensee has already conducted re-training on medication administration and incorporated policy against pre-popping meds for residents. Licensee agrees to conduct a staff meeting to remind staff of this and provide example of possible consequences of med errors. Licensee may self-ceritfy once complete.
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Based on record review and interviews conducted, the Licensee did not comply with the above regulation with 1 resident. On 11/20/20, S1 administered the wrong medication to R1, which resulted in an allergic reaction and R1 going to the ER. This was an immediate health risk to R1.
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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: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 7
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
09/02/2021 and conducted by Evaluator Crystal Colvin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210902121126

FACILITY NAME:VIA GENOAFACILITY NUMBER:
331800484
ADMINISTRATOR:EDGINGTON, JOHN TFACILITY TYPE:
735
ADDRESS:47018 VIA GENOATELEPHONE:
(760) 262-5957
CITY:INDIOSTATE: CAZIP CODE:
92201
CAPACITY:4CENSUS: 4DATE:
11/08/2022
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Paulina Corona - House ManagerTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Facility staffed failed to ensure resident had a proper oral hygiene regimen.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unanounced in order to deliver findings of a complaint with the above allegation(s). LPA identified herself and discussed the purpose of the visit with House Manager Paulina Corona. Below is a summary of the findings:

Regarding allegation "Facility staffed failed to ensure resident had a proper oral hygiene regimen.": LPA Colvin reviewed relevant records in R1’s file as well as conducted interviews with staff responsible for R1’s care. LPA Colvin observed that a note from an IDT Meeting for R1 that was conducted on 6/10/20 states that R1 is to brush their own teeth and that staff are responsible for providing prompts to R1. It was additionally noted that as of the date of the note, all dental appointments are on hold due to COVID-19. LPA Colvin additionally observed in R1’s file at the facility documentation (Data Collection) where staff list “Y” or “N” for each shift for specific items the facility is tracking for R1. Brushing of R1’s teeth was included in this form. LPA Colvin observed completed tracking logs for multiple months in 2020, as well as August 2021.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 18-AS-20210902121126
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: VIA GENOA
FACILITY NUMBER: 331800484
VISIT DATE: 11/08/2022
NARRATIVE
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LPA Colvin observed varying data for each month, as some months R1 brushed their teeth nearly every morning, and other months R1 brushed their teeth less than half of the days of the month. LPA Colvin interviewed staff at the facility regarding R1’s grooming routine, and what the staff do to encourage R1 to brush their teeth. Staff interviews revealed that staff will encourage R1 multiple times to brush their teeth each shift prior to noting a refusal. LPA Colvin inquired about R1’s dental health and if staff observed anything abnormal during their supervision of R1 while R1 brushes their teeth. Interviews did not reveal any reported observations of anything out of the ordinary with R1’s teeth, just some bleeding when brushing. Therefore, due to presence of documentation of R1’s brushing habits, staff interviews confirming prompting for R1 to brush teeth, the allegation “Facility staffed failed to ensure resident had a proper oral hygiene regimen.” Is UNSUBSTANTIATED.

A finding of UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted with House Manager Paulina Corona and a copy of this report was provided
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 7