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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 340312629
Report Date: 03/28/2022
Date Signed: 03/28/2022 11:26:28 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/24/2022 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 25-AS-20220224134124
FACILITY NAME:NAVARRO RESIDENTIAL CAREFACILITY NUMBER:
340312629
ADMINISTRATOR:NAVARRO, ANGELFACILITY TYPE:
740
ADDRESS:7327 SOVEREIGN COURTTELEPHONE:
(916) 721-0452
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY:6CENSUS: 4DATE:
03/28/2022
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Lito Navarro, LicenseeTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Facility has bed bugs

AM medication for resident was improperly stored as a PM medication
INVESTIGATION FINDINGS:
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On 3/28/2022, Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Licensee, Lito Navarro, to deliver findings into the complaint allegations listed above. LPA wore an N-95 mask while inside the facility.

During the investigation, LPA conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows:

Allegation: Facility has bed bugs

A Facility Action Report (FAR) was generated by Alta California Regional Center (ACRC) on 3/8/2022 to address violations per Title 17 regulations. Information on the FAR is as follows:

** Report continued to 9099-C **
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2022
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 25-AS-20220224134124
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: NAVARRO RESIDENTIAL CARE
FACILITY NUMBER: 340312629
VISIT DATE: 03/28/2022
NARRATIVE
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On 2/23/2022, ACRC Service Coordinator was notified that a resident (R1) had been observed by conservator to have red marks appearing to be bug bites. On 2/24/2022, ACRC staff conducted an unannounced visit at the facility and observed both live and dead bed bugs in two client bedrooms. Following inspection, ACRC staff requested clients to be relocated to the identified emergency relocation site and clients were relocated 2/24/2022. Facility was treated for bed bugs on 2/25/2022 with invoices provided to ACRC and CCLD. Clients returned to facility after treatment for bed bugs. Facility will be receiving ongoing bedbug inspections once every two months or as needed.

Allegation: AM medication for resident was improperly stored as a PM medication

A FAR was generated by ACRC on 3/8/2022 to address violations per Title 17 regulations. Information on the FAR is as follows:

On 2/23/2022, ACRC Service Coordinator was notified that R1’s conservator had been provided R1's medication in which morning doses of Glipizide was stored with evening medications. Licensee did not identify which medication tablets were to be administered at the appropriate times during the medication transfer to conservator.

During visit conducted on 3/28/2022, LPA reviewed Centrally Stored Medication Form and MAR for R1 and observed medication Levothyroxine was administered twice a day at 8:00 AM and 5:00 PM daily despite Centrally Stored Medication Form and MAR indicating that Levothyroxine was to be administered 1 tab daily. Licensee stated that the facility did not have anything in writing indicating that Levothyroxine should be administered more than 1 tab daily. PRN medications for R1 were also missing from Centrally Stored Medication Form.

Based on records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D.

Exit interview was conducted with Licensee. A copy of this report and appeal rights were provided. The Licensee’s signature on these forms acknowledges receipt of these documents.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 25-AS-20220224134124
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: NAVARRO RESIDENTIAL CARE
FACILITY NUMBER: 340312629
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/29/2022
Section Cited
CCR
87465(a)(5)
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility (...) by compliance with the following: (5) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
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Facility completed an ACRC Med Training on 3/23/2022. Facility will conduct an in-service with staff on Medication Administration by 4/8/2022 according to FAR from ACRC. Licensee will submit to LPA information regarding in-service training, including time and date of in-service and training material, by POC due date of 3/29/2022.
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Based on interviews conducted and records reviewed, the facility did not ensure R1 was receiving medications as perscribed, which poses an immediate health, safety, and personal rights risk to the residents in care.
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Type B
04/11/2022
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
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Facility will be treated for bed bugs with follow-up pest control treatment inspections scheduled every 2 weeks for up to 3 months. Facility will also create a tracking tool to ensure that facility staff check for bed bugs on a daily basis.
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Based on interviews conducted and records reviewed, the facility did not ensure a clean, safe, and sanitary environment for residents, resulting in a bed bug infestation, which poses a potential health, safety, and personal rights risk to the residents in care.
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Licensee will submit to LPA tracking tool staff use to check for bed bugs daily, as well as receipt for upcoming bed bug treatment inspection, by POC due date of 4/11/2022.
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: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2022
LIC9099 (FAS) - (06/04)
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