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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881043
Report Date: 03/14/2024
Date Signed: 03/14/2024 01:14:10 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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
01/25/2024 and conducted by Evaluator Ryan Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20240125090322
FACILITY NAME:NOAH'S ARK ADULT HOMEFACILITY NUMBER:
331881043
ADMINISTRATOR:ANGUIANO, RUTHFACILITY TYPE:
735
ADDRESS:20094 KLYNE ST.TELEPHONE:
(951) 707-6803
CITY:CORONASTATE: CAZIP CODE:
92881
CAPACITY:4CENSUS: 2DATE:
03/14/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Ruth Anguiano- AdministratorTIME COMPLETED:
01:20 PM
ALLEGATION(S):
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Staff are not providing resident's medication.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to deliver findings for the allegation listed above. LPA stated the purpose of the visit, was granted entry, and met with Administrator Ruth Anguiano. The investigation consisted of client interviews, staff interviews, and document review.

For allegation, Staff are not providing resident's medication. It was alleged that Client C1 was not administered medication as prescribed by the doctor.

Interviews with the staff revealed that C1 was not administered their medication as prescribed by the doctor. The staff admitted that one (1) of C1’s medications was only administered when C1 had symptoms that required the medication. Additionally, C1 was prescribed a new medication on 1/17/2024. The facility staff did not administer the new medication until 1/23/2024. The facility staff stated the reason for not administering the medication was due to being concerned that the new medication would interfere with a prior medication.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024
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-20240125090322
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: NOAH'S ARK ADULT HOME
FACILITY NUMBER: 331881043
VISIT DATE: 03/14/2024
NARRATIVE
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The staff contacted C1’s doctor on 1/17/2024 and left a message with the doctor due to the doctor being out of the office. The facility staff did not administer the new medication until the staff received communication from the doctor on 1/23/2024.The facility staff did not reveal any additional measures or contacts, such as contacting a pharmacy and or a nurse hotline, that were made to verify if the new medication would interfere with C1’s current medication.

Interviews with the clients revealed that the clients did not have any concerns about their medications being administered.

A document review of email communication between C1’s family member and the Administrator revealed that a new medication was dropped off at the facility for C1 on 1/17/2024. The facility staff informed C1’s family member that the medication would not be administered until the staff spoke to C1’s doctor’s office. A document review of C1’s medication record (MAR) revealed that one (1) of C1’s medication was ordered to be administered once daily or every other day for maintenance. In the month of December 2023, this medication was only administered eight (8) days out of the thirty-one (31) calendar days. Additionally, C1’s new medication that was received on 1/17/2024 was not administered the until 1/23/2024.

Based on the evidence gathered during the investigation, the allegation listed above is deemed SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of evidence the standard has been met.

During today’s visit, one (1) deficiency was cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC9099), LIC9099D, and LIC811 were discussed and provided Administrator Ruth Anguiano, along with a copy of the appeal rights.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20240125090322
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: NOAH'S ARK ADULT HOME
FACILITY NUMBER: 331881043
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/15/2024
Section Cited
CCR
80075(b)
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80075 Health Related Services (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.
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The licensee has agreed to read regulation 80075 entirely and send LPA a statement of understanding that the regulation was read and understood. The licensee has agreed to conduct medication training with the staff and send LPA proof of attendance. POC is due by 3/15/24.
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This requirement is not met as evidenced based on document review and interview, the licensee did not comply with the section cited above evidenced by not assisting C1’s with medication as prescribed by the doctor which poses an immediate health, safety, or personal rights risk to persons in care.
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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.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3