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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880803
Report Date: 01/27/2023
Date Signed: 01/27/2023 01:23:36 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
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/09/2022 and conducted by Evaluator Bernadette Allen
COMPLAINT CONTROL NUMBER: 56-AS-20221209161254
FACILITY NAME:ENJOYCARE-POPLARFACILITY NUMBER:
331880803
ADMINISTRATOR:SUSAN FRIESFACILITY TYPE:
740
ADDRESS:11574 POPLAR STREETTELEPHONE:
(909) 796-1375
CITY:LOMA LINDASTATE: CAZIP CODE:
92354
CAPACITY:6CENSUS: 5DATE:
01/27/2023
UNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Susan Fries Administrator .TIME COMPLETED:
01:25 PM
ALLEGATION(S):
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Staff are mismanaging residents medications.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to initiate a complaint investigation for the allegation(s) above. LPA Allen met with Susan Fries who was informed of the purpose of the visit.

Allegation- Staff failed to dispense medication as prescribed by physician.

During the investigation LPA observed that the resident’s medications were removed from the original package and placed in a medication dispensary and documents were signed by the administrator not by the staff member who dispensed the medication.LPA interviewed staff members S1, S2, and S3 and staff stated that the medications are separated prior to giving medications to the resident but they are always given on time.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette AllenTELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023
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 56-AS-20221209161254
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
, CA 92507
FACILITY NAME: ENJOYCARE-POPLAR
FACILITY NUMBER: 331880803
VISIT DATE: 01/27/2023
NARRATIVE
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LPA interviewed residents (R1), (R2), (R3),( R4) and (R5) and the residents in care stated that their medications are provided to them on a daily basis. The interviews conducted with staff (S1), (S2) and (S3) confirmed that medications are removed from the original package and then dispensed to the resident’s and later signed by the administrator. Based on interviews, observation and documentation gathered during the investigation, the above allegation is found to be Substantiated.

A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. A deficiency is being cited on the attached LIC 9099-D for mismanaging residents medications.

LPA conducted an exit interview where this report was discussed with Susan Fries and a copy of this report LIC9099, 9099-C and LIC 9099-D with appeal rights were provided at the conclusion of the visit
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette AllenTELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20221209161254
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
, CA 92507

FACILITY NAME: ENJOYCARE-POPLAR
FACILITY NUMBER: 331880803
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/27/2023
Section Cited
CCR
87465(h)1-6
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Incidental Medical and Dental Care-The following requirements shall apply to medications which are centrally stored:Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.
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The licensee has agreed to read the cited regulation entirely including all staff members and provide a written statement of understanding signed by all staff members. This document will be forward to CCL by the POC date of 1/28/2023.
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This requirement is not met as evidenced by:
This requirement is not met as evidenced by: During LPA visit observations were made and the residents medications were not in its original packaging and documents/MAR's are not signed by the staff member providing medication. interviews also confirmed that medications are not in original packaging at the time of dispensing
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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) 248-0349
LICENSING EVALUATOR NAME: Bernadette AllenTELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3