342700902-3-6-2024-59-AS-LMUZ-D3QPQZ-20240326113157

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700902
Report Date: 03/06/2024
Date Signed: 03/06/2024 12:48:42 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/14/2023 and conducted by Evaluator Lavinia Muscan

COMPLAINT CONTROL NUMBER: 59-AS-20231214145225

FACILITY NAME:	FOLSOM COUNTRYHOUSE		FACILITY NUMBER:	342700902
ADMINISTRATOR:	LETICIA FERMOSO HIGARES		FACILITY TYPE:	740
ADDRESS:	2005 IRON POINT RD		TELEPHONE:	(916) 836-8022
CITY:	FOLSOM	STATE: CA	ZIP CODE:	95630
CAPACITY:	60	CENSUS: 42	DATE:	03/06/2024
		UNANNOUNCED	TIME BEGAN:	12:14 PM
MET WITH:	Director of Nursing Brian Pawloski		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Resident tested positive for a controlled substance which is not a prescribed medication.

INVESTIGATION FINDINGS:

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On 3/6/24, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Director of Nursing Brian Pawloski.

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

The results of the investigation are as follows:

**Report continued on 9099-C**

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024

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 59-AS-20231214145225

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: FOLSOM COUNTRYHOUSE	FACILITY NUMBER: 342700902
	VISIT DATE: 03/06/2024

NARRATIVE

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Resident tested positive for a controlled substance which is not a prescribed medication.
On 12/7/2023, R1 was taken to the hospital with a chief complaint noted to be “confusion.” While R1 was at the hospital, a urine test was completed, and the results came back showing R1 tested positive for Fentanyl and amphetamine. R1’s prescribed medications list did not include Fentanyl or amphetamine. During the investigation, it was learned R1 is taking a medication called Wellbutrin. Per Hospital medical records, Wellbutrin can cause a false positive for amphetamines. The Director of Nursing and staff stated Folsom Countryhouse does not have any residents who have prescriptions for Fentanyl or amphetamines. Facility staff did not know how R1 tested positive for both Fentanyl and amphetamine. Medication Technicians reported that the medication room and medication cart are both locked, and they stated that the medication room or medication cart has never been left unlocked. Staff were asked if there were any concerns about staff using Fentanyl or amphetamines within Folsom Countryhouse and they said no. Residents were interviewed and had no complaints to report. Through interviews and record review, the Department could not find substantial evidence to support that the allegation occurred. The Department finds this allegation to be UNSUBSTANTIATED - meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted and copy of this report was left with Director of Nursing Brian Pawloski .

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024

LIC9099 (FAS) - (06/04)

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