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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700677
Report Date: 04/05/2022
Date Signed: 04/05/2022 10:50:35 AM

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
03/28/2022 and conducted by Evaluator Christina Valerio
COMPLAINT CONTROL NUMBER: 27-AS-20220328171141
FACILITY NAME:MISSION HOME CBN INCFACILITY NUMBER:
342700677
ADMINISTRATOR:CENTENO, CRISELDAFACILITY TYPE:
735
ADDRESS:8591 MISSION FALLS CIRCLETELEPHONE:
(916) 519-7474
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:4CENSUS: 4DATE:
04/05/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Orlando Carpio TIME COMPLETED:
11:05 AM
ALLEGATION(S):
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Facility is mismanaging resident's medication.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christina Valerio and LPA Jamie Ivey-Canady arrived to the facilty unannouced to conduct a 10-Day Visit and complaint investigation. LPAs were met by Co-Administrator Orlando Carpio. LPAs determined the following as it relates to the above allegation.

LPA Valerio reviewed Alta Regional Center Facility Action Report dated 03/24/2022. On 03/17/2022, Alta Regional discovered that the facility was in vioaltion of California Code of Regulations, Title 17 56054(a)(1). LPAs reviewed 2 resident files (R1-R2). Files for R1 and R2 were corrected since Alta Regional's unannouced visit and no additonal medication errors were observed.

Based on record review and interviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations are being cited on the attached LIC-9099D. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided. An exit interview was held and a copy of the report was left at the facility.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022
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 2
Control Number 27-AS-20220328171141
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: MISSION HOME CBN INC
FACILITY NUMBER: 342700677
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/05/2022
Section Cited
CCR
82075(b)(6)(C)
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82075 Health-Related Services (b) Clients shall be assisted as needed with self-administration...(6).. program staff shall be permitted to assist the client... (C)The date and time.. the dosage taken, and the client's response, shall be documented and maintained in the client's record. This requirement was not met as evidenced by:
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Licensee stated they have implemented a double-check system for all residents when staff are passing medications. Licensee stated in-service training will be provided to staff on 04/28/22. Licensee to send documentation for double-check system and in-service training to LPA Valerio by POC due date.
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Based on record review and interviews, the facility did not ensure 2 out of 4 resident's medication administration records were signed and medications were handled properly, which poses an potential health and safety risk to persons 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: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2