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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336426347
Report Date: 09/16/2021
Date Signed: 09/16/2021 05:00:23 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
09/15/2021 and conducted by Evaluator Deborah Mullen
COMPLAINT CONTROL NUMBER: 18-AS-20210915150525
FACILITY NAME:SILVER MOON ASSISTED LIVINGFACILITY NUMBER:
336426347
ADMINISTRATOR:APRIL GERONIMOFACILITY TYPE:
740
ADDRESS:35681 SILVERWEED ROADTELEPHONE:
(951) 926-0570
CITY:MURRIETASTATE: CAZIP CODE:
92563
CAPACITY:6CENSUS: 4DATE:
09/16/2021
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:April Geronimo, Licensee/AdministratorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Residents were administered medications not prescribed by a physician
Residents' medications are not properly disposed of
Residents' medication are not centrally logged
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Deborah Mullen conducted an unannounced visit to investigate the above allegations. LPA conducted an inspection of the facility, interviewed staff and resident.

Interviews with staff revealed resident 1 (R1) was administered an over the counter medication without a doctor's prescription. Per the Administrator, R1's family provided the Administrator with an over the counter melatonin to assist R1 in sleeping. Per the Administrator R1 did not have a current prescription to administer the medication.

During an inspection of the facility on 9/16/21, LPA Mullen observed previous residents medications stored in a cabinet in the garage. Per the Administrator the medication is for residents who are no longer placed at the facility and/or for residents who have passed away.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021
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 6
Control Number 18-AS-20210915150525
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: SILVER MOON ASSISTED LIVING
FACILITY NUMBER: 336426347
VISIT DATE: 09/16/2021
NARRATIVE
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During an inspection of the residents medications on 9/16/21, LPA Mullen observed one of R1's prescription medications not recorded on a centrally stored medication log.

Based upon LPA observations, a review of facility documentation and interviews, the preponderance of evidence standard has been met. Therefore, the allegations are found to be substantiated. California Code of Regulations, Title 22, Division 12, Chapter 6 are being cited as detailed on the attached LIC 9099D. An exit interview was conducted, and a copy of this report was reviewed with and provided to April Geronimo, Licensee.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
09/15/2021 and conducted by Evaluator Deborah Mullen
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210915150525

FACILITY NAME:SILVER MOON ASSISTED LIVINGFACILITY NUMBER:
336426347
ADMINISTRATOR:APRIL GERONIMOFACILITY TYPE:
740
ADDRESS:35681 SILVERWEED ROADTELEPHONE:
(951) 926-0570
CITY:MURRIETASTATE: CAZIP CODE:
92563
CAPACITY:6CENSUS: 4DATE:
09/16/2021
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:April Geronimo, LicenseeTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Residents' food supply is not adequate
Residents' are restrained
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Deborah Mullen conducted an unannounced visit to investigate the above allegations. LPA met with April Geronimo, Licensee. During the inspection, LPA completed a walk through of the facility, reviewed facility records, and interviewed staff.

On 9/16/21, LPA Mullen inspected the food supply at the facility. LPA observed the facility to be supplied with 7 days of non-perishable and 2 days of perishable foods. Staff interviews revealed that food is replenished weekly. Staff denied the facility not having an adequate supply of food for residents in care. Additional information received was that the facility lacked adequate food for the residents in care.


Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 18-AS-20210915150525
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: SILVER MOON ASSISTED LIVING
FACILITY NUMBER: 336426347
VISIT DATE: 09/16/2021
NARRATIVE
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Information was reported that staff restrain residents. LPA inspected the facility and did observe a soft restraint hanging over resident 1's (R1's) wheelchair. Interviews with staff revealed the resident does have a soft restraint that was purchased by the facility, for the resident, with the families permission. The Licensee provided documentation provided by R1's primary care physician, stating R1 was observed with the restraint on and observed to be able to get out of the restraint "on" R1's "accord and at" R1's "own initiation." The Licensee denied there being a prescription from the doctor for the use of the soft restraint, only the documented observation the R1 could get out of the restraint without assistance.

Based upon LPA's observation, a review of facility documentation and a interviews, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of this report was reviewed with and provided to April Geronimo, Licensee.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 18-AS-20210915150525
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: SILVER MOON ASSISTED LIVING
FACILITY NUMBER: 336426347
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/24/2021
Section Cited
CCR
87465(e)
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Incidental Medical and Dental Care: For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information...
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Licensee will return the Melatonin to R1's family and provide documentation as evidence that medication was returned to the family. In addition, Licensee will submit a written statement acknowledging she has reviewed and understand Section 87465.
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This requirement was not being met as evidenced by: During an inspection of the medication on 9/16/21, LPA Mullen observed R1 to have an over the counter bottle of Melatonin, provided to the Licensee by R1's family. The licensee did not have a prescription to administer the medication to R1. This posed a potential health and safety risk to the resident in care.
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Type B
09/17/2021
Section Cited
CCR
87465(i)
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Incidental Medical and Dental Care: Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident.
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Licensee will dispose of medication from previous residents and submit a copy of the LIC 622 Centrally Stored Medication and Destruction Log
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Both shall sign a record, to be retained for at least three years, which lists the following: This regulation was being met as evidenced by: During an inspection of the faciltiy on 9/16/21, LPA Mullen observed multiple prescription medications, from previous residents, stored in a cabinet in the garage. This posed a potential health and safety risk.
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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: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 18-AS-20210915150525
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: SILVER MOON ASSISTED LIVING
FACILITY NUMBER: 336426347
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/24/2021
Section Cited
CCR
87465(h)(6)
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Incidental Medical and Dental: The following requirements shall apply to medications which are centrally stored: (6)The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes...
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Licensee will submit a completed centrally stored medication log for R1's Temazepam and submit a copy to LPA by 9/24/21 as proof of correction.
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This requirement was not being met as evidenced by: During an inspection of the resident's medication on 9/16/21, LPA Mullen observed a medication for R1 which was not recorded on a centrally stored medication log. This poses a potential health and safety risk to resident 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: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 6