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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336424105
Report Date: 02/23/2022
Date Signed: 02/23/2022 03:30:32 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
09/16/2020 and conducted by Evaluator Jennifer Semin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200916081046
FACILITY NAME:VALENCIA TERRACEFACILITY NUMBER:
336424105
ADMINISTRATOR:DYAN SUMMERELLFACILITY TYPE:
740
ADDRESS:2300 SOUTH MAIN STREETTELEPHONE:
(951) 273-1300
CITY:CORONASTATE: CAZIP CODE:
92882
CAPACITY:84CENSUS: 64DATE:
02/23/2022
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Edgar GallardoTIME COMPLETED:
02:20 PM
ALLEGATION(S):
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Facility staff mismanaged resident's medications while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jennifer Semin conducted an unannounced visit to deliver the findings for the above complaint allegation. LPA met with Resident Relations Director, Edgar Gallardo.

The investigation consisted of interviews and review of records. The allegation, Facility staff mismanaged resident's medications while in care. Staff and Resident 1 (R1) stated staff give R1 their medication on time and in correct amount. The Medication Administration Record (MAR) indicates that the medication was not given according to R1's physician’s order and that R1 had refused or refused to take the full dose prescribed on multiple occassions.
Based on interviews and documentation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapter 1) is being cited on the attached LIC9099D.

An exit interview was conducted where this report, LIC9099D, and appeal rights were discussed and provided to Mr. Gallardo.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Jennifer SeminTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022
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-20200916081046
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: VALENCIA TERRACE
FACILITY NUMBER: 336424105
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
02/24/2022
Section Cited
CCR
87465(b)(2)
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If the resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication, facility staff shall be permitted to assist the resident with self-administration of his/her PRN medication.Once ordered by the physician the medication is given according to the
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Licensee shall read this regulation in it's entirety, train staff on this regulation, submit a statement of understanding and training log to CCL by the POC due date of 2/24/2022.
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physician's directions.This regulation was not met as evidenced by, The Medication Administration Record (MAR) indicates that the medication was not given according to R1's physician’s order. This poses a health and safety risk to residents 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.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Jennifer SeminTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022
LIC9099 (FAS) - (06/04)
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