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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700801
Report Date: 10/11/2021
Date Signed: 10/11/2021 11:26:05 AM



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
09/28/2021 and conducted by Evaluator Jacob Williams
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20210928131254
FACILITY NAME:MINNESOTA HOME CAREFACILITY NUMBER:
342700801
ADMINISTRATOR:OKVERE, VERA A.FACILITY TYPE:
740
ADDRESS:7448 MINNESOTA DR.TELEPHONE:
(916) 729-9461
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:6CENSUS: 6DATE:
10/11/2021
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Beatrice Okyere, caregiverTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Staff did not maintain records of centrally stored prescription medications
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jacob Williams and Bethany Mirlohi arrived unannounced to deliver findings for allegation listed above. LPA met with caregiver Beatrice Okyere during today’s inspection. LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Masks.

LPA’s investigated allegation, “Staff did not maintain records of centrally stored prescription medications”. LPA’s reviewed 4 client medications comparing with physician orders and Centrally Stored Medication Record (CSMR). LPA’s observed R1 had three missing medications that were on their medication orders but not present in the facility. In addition, LPA’s observed 12 medications were not recorded on the CSMR.

CONTINUED ON LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Jacob WilliamsTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2021
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 5
Control Number 25-AS-20210928131254
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: MINNESOTA HOME CARE
FACILITY NUMBER: 342700801
VISIT DATE: 10/11/2021
NARRATIVE
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LPA’s observed R2 had 2 missing medications that were on their medication orders but not present in the facility, and 1 medication being given to resident did not have physician orders in place. In addition, LPA observed 1 medication that was not recorded on the CSMR. LPA’s observed R3 had 5 missing medications that were on their medication orders but not present in the facility and 1 medication not documented on the CSMR. LPA observed R4 had 10 missing medications that were on their medication orders but not present in the facility and 7 medications were not documented on the CSMR.
Due to the information gathered LPA finds allegation 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. Civil penalties have been assessed.

Exit interview conducted and appeal rights given.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Jacob WilliamsTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 25-AS-20210928131254
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: MINNESOTA HOME CARE
FACILITY NUMBER: 342700801
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/11/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/12/2021
Section Cited
CCR
87465(a)(5)
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87465 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: (5) The licensee shall assist residents with self-administered medications as needed.
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Licensee agrees to schedule doctor appointments for all residents in care for a medication review. In addition, administrator to request for updated medication lists and obtain all ordered medications.
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This requirement is not met as evidenced by: Based on record review and observation, Licensee did not provide prescribed medications to clients which is an immediate threat to the health and safety of residents in care.
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Licensee to send to CCL doctor appointments that were scheduled for residents and fax confirmation sheets showing a request for updated medication orders to residents’ primary care physician. POC due by 10/12/21. Civil penalties assessed.
Type B
10/25/2021
Section Cited
CCR
87465(h)(6)
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87465 Incidental Medical and Dental Care. (h)The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year.
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Licensee agrees to document all resident medications on the CSMR. Administrator to send into CCL updated CSMR of all residents in care to CCL by 10/25/2021.
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This requirement is not met as evidenced by: Based on observation, Licensee did not record medications on CSMR which is an potential threat to the health and safety of 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: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Jacob WilliamsTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
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
09/28/2021 and conducted by Evaluator Jacob Williams
COMPLAINT CONTROL NUMBER: 25-AS-20210928131254

FACILITY NAME:MINNESOTA HOME CAREFACILITY NUMBER:
342700801
ADMINISTRATOR:OKVERE, VERA A.FACILITY TYPE:
740
ADDRESS:7448 MINNESOTA DR.TELEPHONE:
(916) 729-9461
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:6CENSUS: 6DATE:
10/11/2021
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Beatrice Okyere, caregiverTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Facility is operating outside of license terms and conditions
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jacob Williams and Bethany Mirlohi arrived unannounced to deliver findings for allegation listed above. LPA met with caregiver Beatrice Okvere during today’s inspection. LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Masks.
LPA investigated allegation, “Facility is operating outside of license terms and conditions”. LPA’s toured the facility, interviewed administrator and reviewed facility documents. Facility lease states, “The part of the house located at 7448 Minnesota Dr. which is designated and licensed as an RCFE- Residential Care Facility for elderly and the first storage building in the backyard. Does not include the front private residence in the building, the detached garage and the other storage building in the backyard.” LPA’s toured the “private residence” area and observed administrator is running a room and board in the front portion of the building and has a separate lease for the “private residence”.

CONTINUED ON LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Jacob WilliamsTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 25-AS-20210928131254
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: MINNESOTA HOME CARE
FACILITY NUMBER: 342700801
VISIT DATE: 10/11/2021
NARRATIVE
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LPA’s observed administrator is providing care for 2 clients in the unlicensed portion of the home. A non-compliance conference were be held to discuss facility and the facility leases. LPA finds allegation to be UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are Unsubstantiated.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Jacob WilliamsTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5