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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880967
Report Date: 08/11/2023
Date Signed: 08/11/2023 01:04:10 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
08/07/2023 and conducted by Evaluator Janira Arreola
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230807084041
FACILITY NAME:GARDEN OF EDEN CARE HOMEFACILITY NUMBER:
331880967
ADMINISTRATOR:HOLMES-OTTO, REGINAFACILITY TYPE:
740
ADDRESS:31241 CASERA COURTTELEPHONE:
(951) 388-6204
CITY:MENIFEESTATE: CAZIP CODE:
92584
CAPACITY:6CENSUS: 1DATE:
08/11/2023
UNANNOUNCEDTIME BEGAN:
09:32 AM
MET WITH:Licensee/ Administrator, Regina Holmes-OttoTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Staff are mismanaging resident's medication(s).
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced visit to the facility in order to investigate the above allegations. LPA met with Licensee/ Administrator, Regina Holmes-Otto, who was informed of the purpose of the visit. During the visit, LPA conducted interviews, documented observations, and conducted records reviews.

It was alleged the facility was mismanaging the resident's medications. LPA interviewed the licensee who stated that they had provided another resident's medications to Resident #1 (R1) when they were discharged from the facility. Licensee stated they had R1's medication as well as Resident #2 (R2)'s medication on a table in the kitchen, and stated they had grabbed one of R2's medications and placed them with R1's medications by mistake. LPA observed R2's medication on the kitchen table during the time of the visit. LPA had licensee lock the medications immediately. Therefore, the allegation that the licensee mismanged the resident's medication is substantited.

Substantited findings were cited under California Code of Regulations Title 22. Plan of correction was created with licensee. An exit interview was conducted where this report was reviewed and provided to licensee Regina Holmes- Otto, along with deficency page, 811 and appeal rights.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023
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-20230807084041
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: GARDEN OF EDEN CARE HOME
FACILITY NUMBER: 331880967
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/12/2023
Section Cited
CCR
87465(h)(2)
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(h)...medications which are centrally stored: (2)...shall be kept in a safe and locked place...This requirment was not met as evidenced by:
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The licensee agree to send the LPA a written statement stating that they will ensure all medication is kept locked and will keep documentation for medication taken with a resident upon discharge.
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Based on interview and observation it was found that centrally stored medication for R2 was unlocked and provided to R1 upon discharge. This poses an immediate health safety or personal rights risk.
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This POC is due to the LPA by the POC due date.
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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 EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3