<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002831
Report Date: 11/30/2023
Date Signed: 11/30/2023 10:14:14 AM


Document Has Been Signed on 11/30/2023 10:14 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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



FACILITY NAME:PEOPLE'S CARE KRANS COURTFACILITY NUMBER:
345002831
ADMINISTRATOR:BRITT, AMANDAFACILITY TYPE:
735
ADDRESS:8530 KRANS COURTTELEPHONE:
(909) 287-3557
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY:4CENSUS: 3DATE:
11/30/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Diamond AndersonTIME COMPLETED:
10:30 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 11/30/23, Licensing Program Analysts (LPAs) Cheyenne Ratajczak and Talwinder Bains arrived at the facility to conduct a Case Management visit regarding an incident that occurred on 10/27/23, 11/07/23 and 11/08/23. LPA met with Administrator Diamond Anderson and explained the reason for the visit.

Alta California Regional Center Special Incident Report (SIR) submitted by facility on 10/28/23 and 11/09/23 to Community Care Licensing (CCL) stated that facility did not give scheduled medications to residents (R1,R2).

1st SIR for 10/28/23- Based on incident report, staff interviews, medication record review and observation from the facility, R1 was supposed to receive, Paliperidone ER 9mg tablet at 2pm on 10/27/23 but staff did not give this medication to R1 as ordered by R1s physician. Facility noticed the medication error on 10/28/23 during audit. Facility notified R1s physician, CCL, ALTA and other agencies regarding this medication error on 10/28/23. Per facility’s reports, there were no changes to R1s health due to this med error and R1 was at their baseline.

2nd SIR for 11/09/23- Based on incident report, staff interviews, medication record review and observation from the facility, R2 was supposed to receive, Nortel 1/35 tablet daily as ordered by R2s physician. Per SIR, R2 did not get this medication on 11/07/23 and 11/08/23 as this medication was not refilled/delivered by pharmacy and facility did not make sure that R2 have their medications refilled/delivered in timely manner. Facility management found out on 11/09/23 that R2 did not have their medications refilled/delivered. Facility did not ensure that R2 have medications refilled/delivered ordered by R2s physician in timely way which resulted R2 missed their medications on 11/07/23 and 11/08/23.

Based on this information, it was determined that the facility did not administer this medication to R1 and R2 which poses a immediate health and safety risk to residents in care. Deficiencies are cited pursuant to California Code of Regulations, Title 22, Section 80075(b)(5)(B) and documented on the attached LIC809D.
The report was reviewed, appeal rights and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Cheyenne RatajczakTELEPHONE: (916) 969-7879
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 11/30/2023 10:14 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: PEOPLE'S CARE KRANS COURT
FACILITY NUMBER: 345002831

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/01/2023
Section Cited
CCR
80075(b)(5)(B)

1
2
3
4
5
6
7
80075 Health Related Services (b)(5)(B) - Once ordered by the physician the medication is given according to the physician's directions.
This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee/Administrator agreed to submit a self-certification of understanding the regulation, 80075 (b)(5)(B) and providing medication training for all staff regarding medication administration and ordering medications in timely way (including refills/delivery) and will submit proof to LPA by POC date 12/01/23.
8
9
10
11
12
13
14
Based on record review from the facility, it has been concluded that facility did not give medications to R1 on 10/27/23 and to R2 on 11/07/23 and 11/08/23 as ordered by residents (R1,R2) physician, which poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Cheyenne RatajczakTELEPHONE: (916) 969-7879
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2