336403275-10-5-2021-18-AS-EMAN-C7LMPF-20211008094700

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336403275
Report Date: 09/29/2021
Date Signed: 10/05/2021 11:24:06 AM

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
03/22/2021 and conducted by Evaluator Stephanie Williams

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210322120630

FACILITY NAME:	PUTTERS LANE ASSISTED LIVING		FACILITY NUMBER:	336403275
ADMINISTRATOR:	COCCHIARO, KAREN EILEEN		FACILITY TYPE:	740
ADDRESS:	43307 PUTTERS LANE		TELEPHONE:	(951) 927-8651
CITY:	HEMET	STATE: CA	ZIP CODE:	92544
CAPACITY:	6	CENSUS: 0	DATE:	09/29/2021
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Juanita Duran		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Mismanagement of medications resulting in death of a resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Stephanie Williams conducted an unannounced visit to the facility in order to deliver findings for the above allegation. LPA Williams identified herself and met with Care Provider, Juanita Duran. The investigation consisted of records review and interviews with staff, residents, and witnesses.

According to records review conducted by Department staff, facility staff called 911 due to Resident #1 (R1) experiencing a change of condition. R1 passed away at the hospital on 2/8/2020. Department staff retrieved Resident #1’s (R1’s) death certificate which listed Septic Shock as R1’s condition resulting in cause of death. Department Staff interviewed Witness #1 (W1) who stated that R1 was receiving hospice services two to three times a week. According to R1’s hospice records, R1 was prescribed Medication #1 (M1) (as needed) on 11/30/2018 and was discontinued on 10/16/19. According to W1, M1 was prescribed for comfort care and is commonly prescribed to hospice patients. W1 stated that a review of hospice notes was conducted and W1 did not find any documentation that R1 was given M1. Hospice notes also indicated that R1's health was

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie Williams	TELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021

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-20210322120630

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: PUTTERS LANE ASSISTED LIVING	FACILITY NUMBER: 336403275
	VISIT DATE: 09/29/2021

NARRATIVE

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declining. Department staff interviewed, Staff #1 (S1) and Staff #2 (S2), who both denied administering M1 to R1. S1 stated that no other resident in the facility was prescribed M1. According to S1, R1’s Medication Administration Record (MAR) was unavailable as the facility staff destroyed the documentation after one year of R1’s passing. S1 stated that R1 was initially placed on hospice due to declining health.

Based on evidence obtained during the investigation, LPA has determined that the above allegation is UNSUBSTANTIATED; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted where this report was discussed and a copy was provided to the Administrator via email.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie Williams	TELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021

LIC9099 (FAS) - (06/04)

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