342700073-1-25-2024-59-AS-MSEY-CZUTZR-20240126141043

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700073
Report Date: 01/25/2024
Date Signed: 01/25/2024 11:59:36 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
10/10/2023 and conducted by Evaluator Angela Hood

COMPLAINT CONTROL NUMBER: 59-AS-20231010092601

FACILITY NAME:	PEOPLE'S CARE WINFIN		FACILITY NUMBER:	342700073
ADMINISTRATOR:	TAUKOSHIUA DOVE-MOSLEY		FACILITY TYPE:	735
ADDRESS:	3418 WINFIN WAY		TELEPHONE:	(916) 480-9660
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY:	4	CENSUS: 3	DATE:	01/25/2024
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Taukoshiua Dove-Mosley, Administrator		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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-Staff do not ensure medication is being correctly dispensed as prescribed to client in care.

INVESTIGATION FINDINGS:

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Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024

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 59-AS-20231010092601

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: PEOPLE'S CARE WINFIN	FACILITY NUMBER: 342700073
	VISIT DATE: 01/25/2024

NARRATIVE

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Allegation: Staff do not ensure medication is being correctly dispensed as prescribed to client in care.
The facility reported medication errors to the Department on 10/9/23, 11/11/23, 11/29/23, and 1/16/24 for residents R1, R2, and R3.

On 10/8/23, when the facility was conducting a medication audit, it was found that, during the 8pm medication pass on 10/6/23, R2 did not receive three (3) of their medications as prescribed. The facility indicated that staff would undergo medication administration training and additional audits would be conducted throughout the week.

On 11/10/23, the facility conducted a medication audit and found that R2 received a 3-day expired PRN medication. Staff (S5) who passed the medication received corrective action from the care home. S5 was required to complete medication administration training as well as have four (4) medication observations conducted by the Program Administrator and/or the Licensed Vocational Nurse. The facility indicated that they switched medications to single bubble packs. Also, the facility indicated that they will be conducting audits during the NOC shift, as well as weekly audits performed by their Quality Assurance Department.

On 11/29/23, the facility found that R1 did not receive their 8am supplement. The facility indicated that they contacted the pharmacy and were informed by the Pharmacist that the supplement can still be given to R1. The facility indicated that staff would undergo medication administration training on 12/7/23 and any staff who did not provide medication as prescribed would face disciplinary action.

On 1/16/24, staff (S6) notified the Program Administrator that they found R3 did not receive one (1) of their 5pm medications on 1/15/24. Program Administrator indicated that they contacted the prescribing physician and were informed that nothing needs to be done regarding the missing medication. Program Administrator indicated that, after further examination, it was determined that staff (S7) conducted the medication pass on 1/15/24. Facility indicated that S7 would be retrained, undergo medication administration observations, and receive disciplinary action.

**********************************************Continued on LIC9099-C*************************************************

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 59-AS-20231010092601

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: PEOPLE'S CARE WINFIN	FACILITY NUMBER: 342700073
	VISIT DATE: 01/25/2024

NARRATIVE

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During a visit conducted on 12/21/23, LPA conducted a medication count for residents R2 & R3 comparing medications stored to the residents’ Centrally Stored Medications Forms (CSMFs). LPA did not observe any errors when comparing R2 and R3’s medications with their CSMFs. Interviews with staff S1, S2, & S3 indicated that they have never observed staff not providing medication as prescribed.

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

Exit interview conducted. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 59-AS-20231010092601

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: PEOPLE'S CARE WINFIN	FACILITY NUMBER: 342700073
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/25/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/26/2024 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Facility agrees to contact residents’ prescribing physician any time there is an error. Facility will complete a statement of understanding by the POC due date of 1/26/24, as well as provide LPA with weekly medication audits for the next month.
	8 9 10 11 12 13 14	Based on documentation reviewed, the facility did not ensure residents (R1, R2, & R3) received medications as prescribed, which poses an immediate health, safety, and personal rights risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 6

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
10/10/2023 and conducted by Evaluator Angela Hood

COMPLAINT CONTROL NUMBER: 59-AS-20231010092601

FACILITY NAME:	PEOPLE'S CARE WINFIN		FACILITY NUMBER:	342700073
ADMINISTRATOR:	TAUKOSHIUA DOVE-MOSLEY		FACILITY TYPE:	735
ADDRESS:	3418 WINFIN WAY		TELEPHONE:	(916) 480-9660
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY:	4	CENSUS: 3	DATE:	01/25/2024
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Taukoshiua Dove-Mosley, Administrator		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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-Staff do not ensure residents were provided clean clothing to wear.
-Staff not providing resident with a diabetic diet.
-Staff do not provide proper food service to clients in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angela Hood arrived unannounced at the care home today, 1/25/24, and met with the Administrator, Taukoshiua Dove-Mosley, to deliver complaint investigation findings into the above stated allegations.

During the course of the investigation, LPA conducted interviews, inspections, and obtained documentation pertinent to the investigation.

Allegation: Staff do not ensure residents were provided clean clothing to wear.
During a visit conducted on 10/12/23, LPA observed the facility staff conducting laundry services. On 10/12/23 and 12/21/23, LPA observed residents to be clean and wearing clean clothing. Interviews conducted with staff (S1, S2, & S3) indicated that they have never observed residents to be wearing dirty clothing. S1 stated that, if a resident gets their clothing dirty during mealtime, staff will change them into clean clothing. S3 stated that the facility does laundry 3-4 times per day and always buys laundry detergent.
**********************************************Continued on LIC9099-C*************************************************

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024

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 59-AS-20231010092601

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: PEOPLE'S CARE WINFIN	FACILITY NUMBER: 342700073
	VISIT DATE: 01/25/2024

NARRATIVE

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Allegation: Staff not providing resident with a diabetic diet.
According to resident (R1’s) physician visit summary dated 2/15/23, R1’s goal blood sugar before a meal is 80-130. R1’s diet during mealtime should consist of ½ a plate of vegetables, ¼ lean protein, and ¼ whole grains. Interviews with S1, S2, and S3 indicated that the facility is following R1’s physician recommended diet. S1 and S3 stated that the facility has sugar free food items for R1. S1 and S2 stated that the facility has postings of their meal plan. S3 indicated that all shifts of facility staff were informed of R1’s diet and a meeting was conducted regarding R1’s diet. S3 stated that staff are to ensure R1’s blood sugar stays at 130. S2 and S3 indicated that R1 should receive more vegetables. S2 stated that the care home has plates split in three sections to help staff portion R1’s food.

Allegation: Staff do not provide proper food service to clients in care.
During visits conducted on 10/12/23 and 12/21/23, LPA observed the facility to have the required 2-day perishable and 7-day nonperishable food supply on hand. Interviews conducted with S1, S2, and S3 indicated that the facility has plenty of food available. Interview with S3 indicated that they grocery shop for the care home every Friday. S3 indicated that the facility has a menu prepared.

Based on interviews conducted, records reviewed, and observation, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted. A copy of this report was provided.

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024

LIC9099 (FAS) - (06/04)

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