340312629-2-2-2024-59-AS-KHOS-D2DSXK-20240212131603

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 340312629
Report Date: 02/02/2024
Date Signed: 02/02/2024 11:47:43 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/05/2024 and conducted by Evaluator Cheyenne Ratajczak

COMPLAINT CONTROL NUMBER: 59-AS-20240105115221

FACILITY NAME:	NAVARRO RESIDENTIAL CARE		FACILITY NUMBER:	340312629
ADMINISTRATOR:	NAVARRO, ANGEL		FACILITY TYPE:	740
ADDRESS:	7327 SOVEREIGN COURT		TELEPHONE:	(916) 502-7140
CITY:	CITRUS HEIGHTS	STATE: CA	ZIP CODE:	95621
CAPACITY:	6	CENSUS: 0	DATE:	02/02/2024
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Maria Canda- Caregiver		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Facility is inaccurately documenting medication administration.

INVESTIGATION FINDINGS:

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On 02/02/24 Licensing Program Analyst (LPA) Cheyenne Ratajczak and Licensing Program Manager (LPM) Laura Munoz arrived at the facility unannounced to deliver final findings for the complaint Community Care Licensing (CCL) received on 01/05/24. LPA met with Caregiver, Maria Canda who called Administrator, Angel Navarro and explained the purpose of the visit.

During the course of the investigation, the Department obtained pertinent documents relevant to the complaint investigation.

Please continue on page LIC 9099-C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Cheyenne Ratajczak	TELEPHONE: (916) 969-7879
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024

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 59-AS-20240105115221

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: NAVARRO RESIDENTIAL CARE	FACILITY NUMBER: 340312629
	VISIT DATE: 02/02/2024

NARRATIVE

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Allegation: Facility is inaccurately documenting medication administration.

Based on the file review of R1s medication administrator records (MAR) it revealed that R1s MAR had the medication, Escitalopram signed for on 12/25/23 and 12/26/23. R1 had not received the medication on either day because the facility had run out of R1s medication with the last dose being on 12/24/23. Facility had then crossed out the initials for, 12/25/23 and 12/26/23, that they had signed for the medication, indicating that R1 never got the medication on those days.

Based on the allegation, facility is inaccurately documenting medication administration, the allegation is SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

The following allegation cited above is substantiated, but no deficiency will be issued as deficiencies were cited during an office meeting that was held on 01/17/2024. The following, California Code Regulation 80075 Health Related Services was cited.

Exit interview conducted, and a copy of the report and appeal rights was provided.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Cheyenne Ratajczak	TELEPHONE: (916) 969-7879
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024

LIC9099 (FAS) - (06/04)

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