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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700630
Report Date: 06/13/2022
Date Signed: 06/13/2022 02:33:19 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/09/2022 and conducted by Evaluator Treana White
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220609140319
FACILITY NAME:L.P. NUNEZ CARE FACILITY #3FACILITY NUMBER:
342700630
ADMINISTRATOR:NUNEZ, LIONELFACILITY TYPE:
735
ADDRESS:8528 BIRCH CREST CTTELEPHONE:
(916) 647-9670
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:4CENSUS: 3DATE:
06/13/2022
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Lionel Nunez, AdministratorTIME COMPLETED:
02:40 PM
ALLEGATION(S):
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Facility has inadequate record keeping of a resident's medication
INVESTIGATION FINDINGS:
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On 06/13//2022 at 1:00pm, Licensing Program Analyst (LPA) T. White arrived unannounced to open and investigate the complaint allegation noted above. LPA met with Administrator, Lionel Nunez and explained the purpose of the visit.

During the course of investigation on 06/13/2022, LPA reviewed Client #1 (C1) Medication Administration Records (MARs) dated for the month of May 2022 and interviewed Staff #1 (S1). Based on MARs, it was observed that between the dates of May 1st- 25th medication Hydroxyzine HCL tab 25 mg was not recorded on the MARs. Based on interview, S1 admitted C1’s Hydroxyzine HCL was not recorded. S1 stated that he called the pharmacy and received an updated MAR with the medication printed on it, so staff could start recording its administration on the evening of 5/25/2022.


Report continues on 9099C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2022
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 27-AS-20220609140319
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: L.P. NUNEZ CARE FACILITY #3
FACILITY NUMBER: 342700630
VISIT DATE: 06/13/2022
NARRATIVE
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S1 stated staff did make a clerical error regarding C1’s medication. Staff did not double check to confirm medication was addedto C1's MARs. S1 stated the medication was still administered between the dates of May 1st- May 25th. However there is no proof indicating medication was given through the dates of May1st – May 25th.

Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview conducted with Administrator. A copy of report and Appeal rights given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20220609140319
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: L.P. NUNEZ CARE FACILITY #3
FACILITY NUMBER: 342700630
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/14/2022
Section Cited
CCR
80075(b)(5)(A)
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8007(b)(5)(A): Health Related Services:(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is(A)There is a written direction from a physician, on a prescription..
This requirement was not met as evidence by:
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Administrator stated nurse consultant in-service training was completed on 05/31/2022. Administrator stated an in- service training with ACRC will be conducted. Administrator agreed to submit proof to LPA once in- service training is completed and correct action report.
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Based on observation and interview, licensee did not comply with the section cited above in 80075(b)(5)(A). Based on interview and observation, between the dates of May 1st- 25th medication Hydroxyzine HCL tab 25 mg was not recorded on the MARs which poses as an immediate health and safety risk to clients 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.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3