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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700961
Report Date: 05/10/2024
Date Signed: 05/10/2024 01:46:49 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH 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
10/02/2023 and conducted by Evaluator Kevin Gould
COMPLAINT CONTROL NUMBER: 27-AS-20231002095822
FACILITY NAME:COMFORTS OF HOME TREASUREFACILITY NUMBER:
342700961
ADMINISTRATOR:KANG, MARIAFACILITY TYPE:
740
ADDRESS:6997 TREASURE WAYTELEPHONE:
(916) 833-1493
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:6CENSUS: 6DATE:
05/10/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Jackie ChanTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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9
1) Resident did not receive medical care in a timely manner
2) Administrator did not conduct a re assessment of residents change in condition.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Kevin Gould made an unannounced inspection to the Comforts of Home Treasure RCFE on 5/10/24 at 9:30am to conclude the investigation of the above allegations and to deliver the findings. LPA Gould met with staff, Jackie Chan and together discussed the investigation details.

Based on the interviews conducted during the investigation process and statements obtained during the investigation process, the allegations cannot be substantiated. LPA was able to confirm through resident and hospital records that R1 was sent to the hospital on 9/27/23 not 9/30/23. The department has determined through staff interviews that R1 was sleepy and refused to get up in the morning of 9/27/23 and refused medications, staff allowed R1 to sleep more, by noon resident still refused to get up. At 2:00pm staff contacted 911 and sent R1 to the hospital for evaluation as at this time, R1 was not responding to staff members.

Repot Continued on LIC 9099-C
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024
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 8
Control Number 27-AS-20231002095822
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: COMFORTS OF HOME TREASURE
FACILITY NUMBER: 342700961
VISIT DATE: 05/10/2024
NARRATIVE
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As a result of R1 being sent to the hospital on 9/27/23, R1 never returned to the facility. R1 passed away prior to returning to the facility. The department has determined that due to the resident not returning the facility, a reassessment could not have been conducted with information obtained from the resident's physician as they did not return to the facility.

The Department has investigated the complaint alleging Neglect/Lack of Supervision. Based on the investigative interviews, record reviews and other supportive evidence, the complaint is determined to be unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. The Complaint has been dismissed.

There are no deficiencies cited per California Code of Regulations, TITLE 22.

Exit interview was conducted with facility staff and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH 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
10/02/2023 and conducted by Evaluator Kevin Gould
COMPLAINT CONTROL NUMBER: 27-AS-20231002095822

FACILITY NAME:COMFORTS OF HOME TREASUREFACILITY NUMBER:
342700961
ADMINISTRATOR:KANG, MARIAFACILITY TYPE:
740
ADDRESS:6997 TREASURE WAYTELEPHONE:
(916) 833-1493
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:6CENSUS: 6DATE:
05/10/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Jackie ChanTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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2
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9
1) Staff administered the incorrect medication(s) to resident resulting in hospitalization.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Kevin Gould made an unannounced inspection to the Comforts of Home Treasure RCFE on 5/10/24 at 9:30am to conclude the investigation of the above allegations and to deliver the findings. LPA Gould met with staff, Jackie Chan and together discussed the investigation details.

Based on the interviews conducted during the investigation process and statements obtained during the investigation process, the department was unable to corroborate the allegations. Per department investigations, no indication that ingesting non-prescribed medication resulted in hospitalization or caused great bodily harm or injury to R1. R1 was treated for an extensive period of time at the hospital for pre-existing conditions that are not relevant to the ingestion of non-prescribed medication. LPA and department review of resident records could not determine how or why R1 had traces of non-prescribed medications in her system but was determined to be not the cause for hospitalization.

Report Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 27-AS-20231002095822
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: COMFORTS OF HOME TREASURE
FACILITY NUMBER: 342700961
VISIT DATE: 05/10/2024
NARRATIVE
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Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of neglect/lack of supervision are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed.

There are no deficiencies is cited per California Code of Regulations, TITLE 22.

Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH 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
10/02/2023 and conducted by Evaluator Kevin Gould
COMPLAINT CONTROL NUMBER: 27-AS-20231002095822

FACILITY NAME:COMFORTS OF HOME TREASUREFACILITY NUMBER:
342700961
ADMINISTRATOR:KANG, MARIAFACILITY TYPE:
740
ADDRESS:6997 TREASURE WAYTELEPHONE:
(916) 833-1493
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:6CENSUS: 6DATE:
05/10/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Jackie ChanTIME COMPLETED:
02:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
1) Staff do not ensure the residents' medications are stored properly.
2) Staff did not follow medication order as prescribed.
3) Staff are not following medication training as required
4) Staff are not following medication destruction as required
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Kevin Gould made an unannounced inspection to the Comforts of Home Treasure RCFE on 5/10/24 at 9:30am to conclude the investigation of the above allegations and to deliver the findings. LPA Gould met with staff, Jackie Chan and together discussed the investigation details.

Based on the interviews and statements obtained during the investigation process, the allegations are substantiated. LPA reviewed Resident records including Medication administration records (MAR), Centrally stored Medication Log, and physically inspected resident medications. LPA also reviewed staff files for staff members administering medications in September 2023. LPAs investigation revealed the following: Regarding staff training, LPA observed initial staff training regarding medication administration but did not observe any annual medications training as required by the health and safety code. LPA observed this for the two staff files reviewed during the investigation.

Report continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 27-AS-20231002095822
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: COMFORTS OF HOME TREASURE
FACILITY NUMBER: 342700961
VISIT DATE: 05/10/2024
NARRATIVE
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Regarding medication being stored properly, LPA did observe for R3, a small plastic zip lock bag with what appeared to be over the counter antacid medications (Tumms). LPA observed the medications to be stored in a plastic bag with no instructions and not in its original container. LPA determined the facility was not storing medications properly.

Regarding Staff did not follow medication order as prescribed, LPA observed for R2, there is a physician's order for an over the counter medication given daily to R2 at a dose of 1,400 mg. LPA observed a bottle of the prescribed over the counter medication but the medication present was only for 1,000 mg. LPA determined the facility staff were administering an over the counter medication at 400 mg less that the physician's order states in R2's file.

Regarding staff are not following medication destruction as required, LPA inspected the centrally stored medication log and reviewed resident's current medications available at the facility. LPA did observe for residents R2 and R3, both had medications present that had either been discontinued or were retained after the discard date listed on the medications instructions. Based on the observations by LPA the above allegations are substantiated.

The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of Medications is substantiated.

The following deficiency is cited per California Code of Regulations, TITLE 22.

Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the home.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 27-AS-20231002095822
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: COMFORTS OF HOME TREASURE
FACILITY NUMBER: 342700961
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/13/2024
Section Cited
CCR
87465(c)(2)
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Incidental Medical and Dental Care: Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by LPA review of resident medications which revealed resident is prescribed fish oil at 1,400mg per dose
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Facility has agreed to review all resident medications, obtain the most current physician orders for all medications, all residents, obtain correct dosages of medications prescribed by physician's, facility will review and document monthly.
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and the medication at the facility was only for 1,000mg so the resident was not receiving medication as ordered by the physician which poses an immediate health, safety or personal rights risk to residents in care.
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Type A
05/13/2024
Section Cited
CCR
87465(h)(5)
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Incidental Medical and Dental Care: Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement was not met as evidenced by LPAs observations of medications stored for R3 which included
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Facility has agreed to review all resident medications and ensure they are stored in the correct and original containers. Facility will review and document monthly.
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antacids stored in a zip lock bag and not in it's original container which poses an immediate health, safety or personal rights 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: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 27-AS-20231002095822
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: COMFORTS OF HOME TREASURE
FACILITY NUMBER: 342700961
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/13/2024
Section Cited
CCR
87465(i)
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Incidental Medical and Dental Care: Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the
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Facility has agreed to review all resident medications and will ensure all medications discontinued or expired are disposed of in accordance with regulations and facility will review and documents Centrally stored destruction record monthly.
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resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years, which lists the following: This requirement was not met as evidenced by LPA review of resident medications observed medications for R2 and R3 who's medications orders had been terminated or medications had exceeded the discard date present in the resident's medication box and not disposed of per regulations which poses an immediate health, safety or personal rights risk to residents in care.
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Type A
05/13/2024
Section Cited
HSC
1569.69(b)
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Employees assisting residents with self-administration of medication; training requirements: each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of
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Facility has agreed to provide training by an RN or LVN. and update all staff files for staff who administer medications to residents. facility will provide documentation of scheduled training by POC due date.
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medicines, shall also complete eight hours of in-service training on medication related issues in each succeeding 12-month period. This requirement was not met as evidenced by the facility only conducted initial medication administration training and did not conduct the required annual training which poses an immediate health, safety or personal rights 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: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024
LIC9099 (FAS) - (06/04)
Page: 8 of 8