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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881115
Report Date: 07/28/2022
Date Signed: 07/28/2022 02:22:01 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
07/21/2022 and conducted by Evaluator Crystal Colvin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220721143820
FACILITY NAME:ANGEL'S LOVING TOUCHFACILITY NUMBER:
331881115
ADMINISTRATOR:CERDA, YAZMIN S.FACILITY TYPE:
740
ADDRESS:37212 EDGEMONT DRIVETELEPHONE:
(951) 249-9041
CITY:MURRIETASTATE: CAZIP CODE:
92563
CAPACITY:6CENSUS: 4DATE:
07/28/2022
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Jazmin Cedra - AdministratorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff failed to safeguard resident's medications.
INVESTIGATION FINDINGS:
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On today's date, Licensing Program Analysts (LPAs) Crystal Colvin and Chinwe Nwogene arrived at the facility unannounced for the purpose of initiating an investigation with the above allegation. LPAs Colvin and Nwogene met with Administrator Jazmin Cedra. Below is a summary of the findings of the investigation:

Regarding allegation "Staff failed to safeguard resident's medications": LPA Colvin reviewed facility medication storage location as well as records for residents' medication. LPA Colvin additionally interviewed Administrator regarding the allegation. Administrator Jazmin Cedra denied any knowledge of any medication missing from the facility for any resident. When LPA Colvin informed her that the Department has photos of another resident's (R1) medication mixed in with other resident medication outside of the facility, Administrator Jazmin Cedra theorized that an error was possibly made when packing up medication for a resident that was discharged from the facility. LPA Colvin inquired as to how the Administrator did not notice the missing medication, and Administrator Jazmin Cedra stated that it was most likely a medication that the facility has extra of for the resident, or a discontinued medication, which is held in a sperate stored location.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2022
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-20220721143820
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: ANGEL'S LOVING TOUCH
FACILITY NUMBER: 331881115
VISIT DATE: 07/28/2022
NARRATIVE
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LPA Colvin observed that the medication that the Department has photos of (Atorvastatin) was not listed on the Centrally Stored Medication Log for R1. Administrator Jazmin Cedra was able to pull a physician's order from R1's file showing that the medication was prescribed to R1 and put on hold pending results of tests.
Based on photographs, interviews, and record review, the allegation "Staff failed to safeguard resident's medications" is SUBSTANTIATED.

A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met.

Due to observations made by LPA Colvin, the facility was cited and deficiencies noted on LIC 9099 D. An exit interview was conducted where this report and appeal rights were discussed. A copy this report, LIC 9099D, and appeal rights were provided to Administrator Jazmin Cedra during the exit interview.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20220721143820
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: ANGEL'S LOVING TOUCH
FACILITY NUMBER: 331881115
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/29/2022
Section Cited
CCR
87465(h)(2)
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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 other than employees... This requirement was not met by:
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Licensee agrees to implement a system to better document all individual bottles/containers of medication in the facility to ensure that if one goes missing, staff can be aware or confirm this immediately. Licensee to additionally submit a Special Incident Report to Licensing as well as inform R1's responsible person (if
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The licensee did not comply with the above regulation with 1 of 4 residents. LPA Colvin confirmed that facility staff accidentally let one of R1's medication be removed from the facility by somone other than an employee or persons responsible for R1. This was an immediate personal rights and health risk of R1.
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any, or if none, R1) of missing medication. Licensee to provide LPA Colvin with details of plan regarding record keeping of medications, copy of submitted Incident Report, and proof of notification to R1 and R1's responsible person (if any). Due by Plan of Correction date of 7/29/22.
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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: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3