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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880585
Report Date: 08/22/2023
Date Signed: 08/22/2023 03:52:02 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, 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
07/26/2023 and conducted by Evaluator Janira Arreola
COMPLAINT CONTROL NUMBER: 18-AS-20230726133735
FACILITY NAME:COOL MEADOW CAREFACILITY NUMBER:
331880585
ADMINISTRATOR:MA SATCHEL LECITAFACILITY TYPE:
740
ADDRESS:29787 COOL MEADOW DRTELEPHONE:
(951) 246-0214
CITY:MENIFEESTATE: CAZIP CODE:
92587
CAPACITY:6CENSUS: 5DATE:
08/22/2023
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Staff, Liz BaclaganTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff do not administer resident's medication as prescribed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced visit in order to deliver findings on the above allegation. LPA met with Staff, Liz Baclagan who was informed of the purpose of the visit. During the investigation LPA conducted interviews, records reviews and observations.

It was alleged the facility did not administer medication #1 (M1) for Resident #1 (R1) as prescribed. R1 takes M1 for a chronic condition, and on 7/24/2023 R1 had an episode of this condition. It was alleged R1 had this episode as a result of not taking M1 for three months. LPA reviewed R1's discharge paperwork which confirmed the diagnosis made by attending phyican which corroborated the allegation; "noncompliance with medication regimen". LPA conducted interview with facility staff who stated that R1 had ran out of M1. LPA reviewed facility documents and found that R1's MARS sheet was not signed off for M1 since 6/22/2023. The staff stated they had not signed off as M1 had ran out and were unable to administer the medication. Therefore the allegation that facility failed to administer M1 to R1 is substantited.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023
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 18-AS-20230726133735
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: COOL MEADOW CARE
FACILITY NUMBER: 331880585
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/23/2023
Section Cited
CCR
87456(a)(4)
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(a)A plan for incidental medical...care shall be developed...(4)The licensee shall assist residents with self-administratered medications as needed.
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The administrator stated they would send a written plan on how they will manage the resident and their medications.
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Based on interviews and records review it was found that R1 had not been given their medication by staff. This poses an immediate health saftey or personal rights risk.
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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: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 18-AS-20230726133735
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: COOL MEADOW CARE
FACILITY NUMBER: 331880585
VISIT DATE: 08/22/2023
NARRATIVE
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Findings that are substantiated mean that the preponderance of the evidence standard has been met. Deficiencies were cited on LIC9099-D page. Plan of correction was created with the administrator Sachel.

An exit interview was conducted with Staff, Liz Baclagan, where this report was reviewed and provided to them along with LIC9099-D page and appeal rights.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3