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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700783
Report Date: 10/06/2021
Date Signed: 10/07/2021 03:29:31 PM



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
09/20/2021 and conducted by Evaluator Michael Smith
COMPLAINT CONTROL NUMBER: 25-AS-20210920163411
FACILITY NAME:7117 MAIN, LLCFACILITY NUMBER:
342700783
ADMINISTRATOR:GLADYS GASTAFACILITY TYPE:
740
ADDRESS:7117 MAIN AVETELEPHONE:
(707) 592-4004
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:6CENSUS: 6DATE:
10/06/2021
UNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Juliet IrunguTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Resident is missing medication
INVESTIGATION FINDINGS:
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Prior to entering the facility, LPA Smith spoke with staff to pre-screen that the facility is COVID free. Analyst also self-screened for having no known symptoms or exposure. Analyst followed facility's screening protocols, wore a mask and maintained distance during the visit. LPA Smith conducted an unannounced complaint visit and met with Juliet Irungu.

Based on the investigation, submitted LIC 624 and witness statements, approximately 12 oxycodone narcotic medication was found to be unaccounted for.

As a result of this investigation, LPA finds the allegation that resident is missing medication to be SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Michael SmithTELEPHONE: (916) 208-7807
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 25-AS-20210920163411
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: 7117 MAIN, LLC
FACILITY NUMBER: 342700783
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/07/2021
Section Cited
CCR
87465(a)(5)
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87465(a)(5)-Incidental Medical and Dental Care-A plan for incidental medical and dental care shall be developed by each facility. The licensee shall assist residents with self-administered medications as needed.
This requirement is not met as evidenced by: Based on interviews, admission and accounting, licensee did not administer
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Facility has implemented a narcotic medication log, where each shift at the beginning and end of each shift will count, document the number and sign off on the number of narcotic medications remaining.

***Deficiency cleared during visit***
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medication in accordance to MD orders. Narcotic medication came up short 12 dosages when counted. This is in violation of this section. This poses an immediate health and safety risk to residents 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.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Michael SmithTELEPHONE: (916) 208-7807
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021
LIC9099 (FAS) - (06/04)
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