342700783-6-2-2022-25-AS-LMUZ-CF9NRG-20220610104132

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700783
Report Date: 06/02/2022
Date Signed: 06/02/2022 12:00:26 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, 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
03/07/2022 and conducted by Evaluator Talwinder Bains

COMPLAINT CONTROL NUMBER: 25-AS-20220307085328

FACILITY NAME:	7117 MAIN, LLC		FACILITY NUMBER:	342700783
ADMINISTRATOR:	GLADYS GASTA		FACILITY TYPE:	740
ADDRESS:	7117 MAIN AVE		TELEPHONE:	(707) 592-4004
CITY:	ORANGEVALE	STATE: CA	ZIP CODE:	95662
CAPACITY:	6	CENSUS: 5	DATE:	06/02/2022
		UNANNOUNCED	TIME BEGAN:	11:20 AM
MET WITH:	Supervisor Lourdes Pantig		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not provide medications to resident as prescribed.

INVESTIGATION FINDINGS:

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

On 06/02/2022, Licensing Program Analysts (LPAs) Talwinder Bains and Lavinia Muscan arrived at the facility and met with ,Supervisor Lourdes Pantig , to conclude a complaint investigation into the allegation listed above. LPAs wore surgical masks/N95 and was screened by facility upon entry.

During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:
Allegation: Staff did not provide medications to resident as prescribed.

** Report continued on 9099-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: 06/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022

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 25-AS-20220307085328

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
	VISIT DATE: 06/02/2022

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

On 03/11/2022, LPA and LPM conducted a walk through of the facility. LPA and LPM reviewed 3 of 6 resident’s medication log as well as 3 of 6 resident’s medications. Additionally, LPA and LPM conducted interviews.

Staff indicated during an interview that R1’s medication was ordered on 02/14/2022 and delivered to the facility on 03/08/2022. Interviews further indicated that R1’s medication had zero refills therefore additional refills needed to be approved by R1’s physician, which resulted in a delay in R1 obtaining medication timely. Based on a review of the facility MAR (Medication Administrator Record), R1 ran out of medication on 02/24/2022 and did not receive medication until 02/27/2022. Based on additional interviews conducted, the facility did not report to R1’s responsible party that R1 was out of medications and that once R1’s responsible party was made aware that R1 was out of medications, R1’s responsible party brought medication to the facility on 02/28/2022.

Although the facility attempted to order R1’s medication timely, the facility did not notify R1’s responsible party. Based on LPA’s interviews 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 supervisor . A copy of this report and appeal rights were provided. The supervisor ’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: 06/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 25-AS-20220307085328

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: 06/02/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/03/2022 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	By POC date- 06/03/22, 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-06/03/22.
	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 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.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder Bains	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3