331880616-1-30-2024-18-AS-RSTS-D29MP5-20240208084631

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880616
Report Date: 01/30/2024
Date Signed: 01/30/2024 02:56:58 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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
01/26/2024 and conducted by Evaluator Sara Martinez

COMPLAINT CONTROL NUMBER: 18-AS-20240126082057

FACILITY NAME:	ANNA CARE LLC		FACILITY NUMBER:	331880616
ADMINISTRATOR:	BLANCAFLOR, ANNALISA		FACILITY TYPE:	740
ADDRESS:	26461 RIDGEMOOR RD		TELEPHONE:	(951) 309-1622
CITY:	SUN CITY	STATE: CA	ZIP CODE:	92586
CAPACITY:	6	CENSUS: 6	DATE:	01/30/2024
		UNANNOUNCED	TIME BEGAN:	12:52 PM
MET WITH:	Coleena Rom - Caregiver		TIME COMPLETED:	03:06 PM

ALLEGATION(S):

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Staff did not ensure that medication was inaccessible to residents in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced visit to initiate and deliver findings regarding the allegation listed above. LPA was granted entry and met with caregiver Coleena Rom, who was informed of the purpose of the visit.

Regarding the allegation “Staff did not ensure that medication was inaccessible to residents in care”, during the tour of the facility, LPA observed two medication cabinets located in the kitchen open and accessible to residents in care. LPA inquired about the medication cabinets being unlocked and staff stated the cabinets were not locked due to a prior visit from LPA Cheryl Goodrich who had conducted an unannounced visit at the facility earlier today. It was documented that LPA Goodrich left the facility at 11:05am. LPA’s interview with staff revealed they are aware the medication cabinets need to be locked and inaccessible to residents in care at all times.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Sara Martinez	TELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20240126082057

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ANNA CARE LLC	FACILITY NUMBER: 331880616
	VISIT DATE: 01/30/2024

NARRATIVE

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Resident One (R1) Hospice Agency record review reveals on 01/25/2024, a hospice RN documented they found an unused fentanyl patch on the kitchen counter that was accessible to residents in care. Hospice RN documented they destroyed the fentanyl patch. Therefore, based on interviews, observation, and record reviews, the allegation “Staff did not ensure that medication was inaccessible to residents in care” has been deemed SUBSTANTIATED at this time.

A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. The facility will be cited pursuant to Title 22, regulation 87464(h)(2).

An exit interview was conducted where a copy of this report was reviewed and provided along with LIC9099-D and Appeal Rights.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Sara Martinez	TELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 18-AS-20240126082057

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ANNA CARE LLC	FACILITY NUMBER: 331880616
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/30/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/31/2024 Section Cited CCR 87464(h)(2)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care: (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons...This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee agrees to provide training to all staff on the importance of keeping all medications locked at all times when not in use. Licensee will submit proof of staff training to LPA by the POC date 01/31/2024.
	8 9 10 11 12 13 14	Based on interviews, observations, and record review, Licensee did not ensure medications were inaccessible to residents in care as LPA observed the medication cabinets open and accessible to the residents which poses an immediate health and safety risk.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Sara Martinez	TELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

LIC9099 (FAS) - (06/04)

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