331880632-3-2-2022-18-AS-NBRN-CESPRU-20220526113318

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880632
Report Date: 03/02/2022
Date Signed: 03/02/2022 10:28:15 AM

Unsubstantiated

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
02/25/2022 and conducted by Evaluator Amy Goldenberg

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20220225161442

FACILITY NAME:	MIRA LOMA SENIOR CARE		FACILITY NUMBER:	331880632
ADMINISTRATOR:	DHUNNA, RAJNISH K		FACILITY TYPE:	740
ADDRESS:	12400 DAKOTA RIVER CT		TELEPHONE:	(951) 444-6661
CITY:	EASTVALE	STATE: CA	ZIP CODE:	91752
CAPACITY:	6	CENSUS: 4	DATE:	03/02/2022
		UNANNOUNCED	TIME BEGAN:	08:20 AM
MET WITH:	Pavani Amarasinghe, Caregiver Rajnish Dhunna, Licensee/Admibnistrator		TIME COMPLETED:	10:45 AM

ALLEGATION(S):

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Staff withholding resident's medication

INVESTIGATION FINDINGS:

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This unannounced visit conducted by Amy Goldenberg, Licensing Program Analyst (LPA), is being conducted to initiate the 10 day visit to investigate the above-mentioned complaint allegation.

During the course of this investigation LPA interviewed one (1) staff, Interviewed four (4) of four (4) residents, and reviewed medications, the medication assistance logs and centrally stored medication logs for R1.

It is alleged that the facility staff are withholding the medication percocet from R1. Investigation revealed the following: R1 has lived at the facility since 10/28/2021. One (1) of four (4) residents interviewed report that R1 often yells at staff for not giving their medications. Two (2) of four (4) residents interviewed do not report issues with not receiving their medications.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022

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-20220225161442

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: MIRA LOMA SENIOR CARE	FACILITY NUMBER: 331880632
	VISIT DATE: 03/02/2022

NARRATIVE

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R1 reports that staff will not give them their pain medication percocet when they ask for it. Staff interviewed report that R1 frequently goes to the hospital, as often as twice daily, that R1 frequently asks for pain medication before it is time for the next dose, and that R1 will claim that staff did not give them the medication at all. Staff deny ever withholding R1s pain medication, reporting that medications are given when asked for. Review of medication orders and centrally stored medication logs revealed that the medication percocet is ordered as needed (PRN) to be given every 8 hours for pain. The staff maintains centrally stored medication log as well as record of PRN medications given. R1's medications are received from the pharmacy in bubble packs and is easily accounted for. LPA has not obtained any evidence during this investigation that would support or refute the allegation that staff are withholding medications from R1 as alleged.

We have found the complaint allegation is unsubstantiated, although the allegation may have happened or is valid: there is not a preponderance of the evidence to prove that the alleged violation occurred. A copy of this report is being reviewed with and furnished to the facility representative.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022

LIC9099 (FAS) - (06/04)

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