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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701155
Report Date: 04/10/2025
Date Signed: 04/10/2025 10:57:00 AM

Substantiated


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
02/04/2025 and conducted by Evaluator Vincent Moleski
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250204125127
FACILITY NAME:MILESTONE CAREHOME INCFACILITY NUMBER:
342701155
ADMINISTRATOR:MERCADO, JENNIFERFACILITY TYPE:
735
ADDRESS:9001 GENERATIONS DRTELEPHONE:
(916) 478-0478
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:4CENSUS: 4DATE:
04/10/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Monalie Pascual-MercadoTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Staff are mismanaging resident's medications.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with facility administrator Monalie Pascual-Mercado and explained the purpose of the visit.

This investigation consisted of observation, interviews, and record review.

LPA Moleski reviewed more than one months' worth of medication administration records (MARs) and centrally stored medication records for four residents. LPA Moleski observed no discrepancies or obvious signs of medication mismanagement.

[continued on 9099-C]
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
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 6
Control Number 27-AS-20250204125127
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: MILESTONE CAREHOME INC
FACILITY NUMBER: 342701155
VISIT DATE: 04/10/2025
NARRATIVE
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LPA Moleski interviewed this facility's only verbal client (R1). R1 did not report any concerns regarding medication management at this facility.

LPA Moleski interviewed six staff members of this facility (S1-S6). In an interview, S1 and S3 said that evening medications were previously given about two hours earlier than they should have been for all clients. S1 and S3 also said that a resident (R2) is given medications as soon as they wake up, even though they are supposed to receive their morning medications with breakfast.

LPA Moleski conducted an audit of daily medications stored at this facility on February 12, 2025. Since the vast majority of residents' medications were packed in bubble packs, or uncountable medications such as powders or liquids, only a handful of medications were able to be reviewed.

LPA Moleski observed discrepancies in R3's medications during this audit. Three medications, all vitamin supplements, were counted out and compared with medication administration records in order to verify if doses were given as prescribed and as documented in facility records. R3 is diagnosed with a vitamin deficiency, and is ordered to take multiple kinds of vitamins daily to counterbalance this deficiency.

R3 had two Vitamin D3 supplements remaining of a 60-count bottle. R3 was supposed to be taking one per day, with a start date recorded as 12/15/24 in their centrally stored medication records log. If one had been taken each day since then, as prescribed and as documented, R3 should have been completely out of supplements as of 2/12/25, the day of the medication audit.

R3 had 130 Centrum multivitamins remaining out of a 150-count bottle. R3 started this bottle on 1/21/25, according to their centrally stored medication records, and was supposed to be taking one vitamin per day. As of the date of review, R3 should have taken 23 doses, meaning that 127 doses should have been remaining.

[continued on 9099-C]
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 27-AS-20250204125127
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: MILESTONE CAREHOME INC
FACILITY NUMBER: 342701155
VISIT DATE: 04/10/2025
NARRATIVE
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R3 had 81 Vitamin C supplements remaining in a 150-count bottle. R3 started this bottle on 1/2/25, according to their centrally stored medication records, and was supposed to be taking two vitamins per day. With two vitamins taken daily over 42 days, R3 should have taken 84 vitamins from the bottle total, which should leave 66.

The department has determined the following as it relates to the allegation that staff are mismanaging residents' medications:

Based on observation, interviews, and record review, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met.

This facility is hereby cited per 22 CCR Section 80075(b). An exit interview was held with Pascual-Mercado. A copy of this report and appeal rights were left with Pascual-Mercado.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 27-AS-20250204125127
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: MILESTONE CAREHOME INC
FACILITY NUMBER: 342701155
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/11/2025
Section Cited
CCR
80075(b)
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"Clients shall be assisted as needed with self-administration of prescription and nonprescription medications." This requirement was not met as evidenced by:
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Licensee has already performed medication trainings in response to the issues documented in this report. LPA Moleski was provided with training records during this visit. This POC will be cleared.
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Based on observation, interviews, and record review, at least one resident was not assisted with medications as needed, which poses an immediate health and safety risk.
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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: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
02/04/2025 and conducted by Evaluator Vincent Moleski
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250204125127

FACILITY NAME:MILESTONE CAREHOME INCFACILITY NUMBER:
342701155
ADMINISTRATOR:MERCADO, JENNIFERFACILITY TYPE:
735
ADDRESS:9001 GENERATIONS DRTELEPHONE:
(916) 478-0478
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:4CENSUS: 4DATE:
04/10/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Monalie Pascual-MercadoTIME COMPLETED:
11:15 AM
ALLEGATION(S):
1
2
3
4
5
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9
Staff do not ensure snacks are available to residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with facility administrator Monalie Pascual-Mercado and explained the purpose of the visit.

This investigation consisted of observation, interviews, and record review. LPA Moleski interviewed facility administrator Jennifer Mercado, six staff members (S1-S6), and one resident (R1). R1 is the only verbal client currently residing at this facility.

LPA Moleski visited this facility on 2/12/25. During that visit, LPA Moleski toured the kitchen and observed sufficient food supplies readily available to residents, including snacks. LPA Moleski observed that a pantry closet was unlocked. During two follow up visits on 3/6/25 and 3/13/25, LPA Moleski observed again that the pantry closet was unlocked. [continued on 9099-C]
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
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 6
Control Number 27-AS-20250204125127
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: MILESTONE CAREHOME INC
FACILITY NUMBER: 342701155
VISIT DATE: 04/10/2025
NARRATIVE
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In an interview, R1 said they are able to access snacks and other food items without issue. In an interview, S1 said that the pantry closet has been locked previously, although there were some snacks stocked in the kitchen for residents. S3 said that when the pantry was locked, about a day's worth of snacks was kept out in the kitchen for residents. No other staff members interviewed voiced concerns regarding the accessibility of food or snacks for residents.

The department has determined the following as it relates to the allegation that staff do not ensure snacks are available to residents:

Based on interviews and observation, the above allegation is UNSUBSTANTIATED, which means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

No deficiencies were cited regarding this allegation. An exit interview was held and a copy of this report was left with Pascual-Mercado.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6