342700766-5-16-2023-59-AS-LMUZ-CRXSGF-20230518135150

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700766
Report Date: 05/16/2023
Date Signed: 05/16/2023 02:11:15 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 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
05/09/2023 and conducted by Evaluator Talwinder Bains

COMPLAINT CONTROL NUMBER: 59-AS-20230509161044

FACILITY NAME:	YELLOWTAIL HOME CARE		FACILITY NUMBER:	342700766
ADMINISTRATOR:	LUI, YING		FACILITY TYPE:	740
ADDRESS:	8513 YELLOWTAIL WAY		TELEPHONE:	(916) 725-2445
CITY:	ANTELOPE	STATE: CA	ZIP CODE:	95843
CAPACITY:	6	CENSUS: 6	DATE:	05/16/2023
		UNANNOUNCED	TIME BEGAN:	01:05 PM
MET WITH:	Administrator, Lui Ying (Ruby)		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not provide resident medications as prescribed.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 05/16/23 to do the complaint investigation for above allegation. LPA met with administrator Lui Ying (Ruby) and explained the purpose of the visit. LPA wore the following Personal Protective Equipment (PPE) during today's visit-surgical mask. LPA was screened by facility staff upon entry.

The department conducted records review ,facility observations and interviews to investigate the complaint.

**Report continued on LIC9099-C**

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder Bains	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

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 59-AS-20230509161044

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: YELLOWTAIL HOME CARE	FACILITY NUMBER: 342700766
	VISIT DATE: 05/16/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

***continued from LIC9099..............

Allegation---Staff did not provide resident medications as prescribed.

Department conducted staff interview, record review for MAR and resident file review for R1 to investigate the complaint allegation. From the record review and staff's interview, it has been observed that the staff was providing R1s medications Sertraline and Amlodipine incorrectly. Staff was given 100 MG of Sertraline which should have been provided 50 MG and staff was giving 5 MG of Amlodipine which should have been provided 10 MG. From the record review, it has been observed that facility staff marked that all residents medications are administered till 05/19/23 with their initials in MAR, which is falsifying the records . Furthermore, from MAR review , it has been found out that facility was not documenting correct dose, month, year for any residents medications including R1 which is immediate health and safety concerns for residents in care.

Based on LPA interview conducted, and record(s) reviewed, the preponderance of evidence standard has been met, therefore the allegation that staff did not provide medication to residents as prescribed is SUBSTANTIATED. found to be SUBSTANTIATED. California Code of regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page.

Exit interview was conducted with Ruby. A copy of this report and appeal rights were provided.
Ruby ’s signature on these forms acknowledges receipt of these documents.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder Bains	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 59-AS-20230509161044

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: YELLOWTAIL HOME CARE	FACILITY NUMBER: 342700766
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/16/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/17/2023 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465(a)(4) 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.	1 2 3 4 5 6 7	Licensee will complete a statement of understanding indicating that the facility is aware of regulation 87465 and will also complete a training regarding medication administration. Facility will submit statement of understanding and schedule for training to department by POC date-05/17/2023.
	8 9 10 11 12 13 14	This requirement is not met as evidence by: Based on records review and interviews conducted, the facility did not ensure R1 had prescribed medication. This poses an immediate health and safety risk to residents	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.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder Bains	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3