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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700949
Report Date: 11/01/2022
Date Signed: 11/01/2022 02:36:44 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, 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
06/23/2022 and conducted by Evaluator Jason Lund
COMPLAINT CONTROL NUMBER: 27-AS-20220623164040
FACILITY NAME:FIELDALE FACILITYFACILITY NUMBER:
342700949
ADMINISTRATOR:HUFF, MARCUSFACILITY TYPE:
735
ADDRESS:6261 FIELDALE DRIVETELEPHONE:
(323) 459-8068
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:4CENSUS: 3DATE:
11/01/2022
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Resident was not provided the proper assistance during transfer to another facility

Resident's MAR was not being followed while in care
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Jason Lund arrived at the above facility to complete a complaint investigation. LPA Lund met with Administrator Michael Oliva and explained the reason for the visit.

Resident was not provided the proper assistance during transfer to another facility- Based on record review, and interviews with staff. Client (C1) was moved from Fieldale Facility on 6/21/2022 to another facility. Records indicate that all C1’s belongings did not get to C1’s new facility until 6/27/2022.
Substantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022
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 27-AS-20220623164040
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: FIELDALE FACILITY
FACILITY NUMBER: 342700949
VISIT DATE: 11/01/2022
NARRATIVE
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Resident's MAR was not being followed while in care. - Based on interviews with staff and record review. Fieldale Facility’s Medication Transfer Sheet/Release of Responsibility dated 6/21/2022 for Client (C1). C1’s Medication Transfer Sheet did not have the pass times on the Medication Transfer Sheet to C1’s new facility.

Based on record review, and interviews, which were conducted along with a file review, the preponderance of evidence has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6 & Chapter number 8) is being cited on the attached LIC 9099D. An exit interview was conducted with Administrator Michael Oliva. A copy of this report was left, and appeal rights were given.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20220623164040
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: FIELDALE FACILITY
FACILITY NUMBER: 342700949
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
11/15/2022
Section Cited
CCR
80026(k)
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Upon discharge of a client, all cash resources, personal property, and valuables of that client which have been entrusted to the licensee shall be surrendered to the client, or his/her authorized representative, if any.
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Administrator will look over the regulation and email LPA Lund proof that he looked over the regualation.
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This requirement was not met as evidenced by the: Records indicate that all C1’s belongings did not get to C1’s new facility until 6/27/2022. This poses a potential health, safety or Personal Rights risk to resident in care.
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Type B
11/15/2022
Section Cited
CCR
80075(k)(7)
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Health Related Services. Licensees shall maintain, for each client, records of centrally stored prescription medications which shall be retained for at least one year.
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Administrator will look over the regulation and email LPA Lund proof that he looked over the regualation.
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This requirement was not met as evidenced by the: C1’s Medication Transfer Sheet did not have the pass times on the Medication Transfer Sheet to C1’s new facility. This poses a potential health, safety or Personal Rights risk to resident 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.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3