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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347003949
Report Date: 08/10/2023
Date Signed: 08/10/2023 11:06:06 AM

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
08/04/2023 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230804152452
FACILITY NAME:HOLY FAMILY HOMEFACILITY NUMBER:
347003949
ADMINISTRATOR:JACKSON, CRISINAFACILITY TYPE:
740
ADDRESS:1440 HOOD ROADTELEPHONE:
(916) 532-7078
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:6CENSUS: 6DATE:
08/10/2023
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Gloria DulayTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff did not follow resident's doctor's medication orders.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced on 08/10/2023 at
10:15 AM to deliver complaint findings, LPA Martinez met with Gloria Dulay and explained the purpose of the visit.

Throughout the course of the investigation, LPA Martinez conducted interviews and reviewed facility files. It was learned staff 1 (S1) was provided an After Visit Summary on August 01, 2023 via text message at
7:53 PM for resident 1 (R1). However, S1 did not update other facility staff of the medication change on the August 01, 2023. The medication change consisted of discontinuing Escitalopram "5MG Tab take two tablets by mouth at bed time, and implementing the new order for Escitalopram, " 5MG Tab take 1 tablet by mouth daily for 14 days then stop". Furthermore, it was learned the new order was implemented on August 04, 2023. As a result the facility did not follow R1's doctors' medication order. Additionally, a case management visit was conducted on August 10, 2023 in regards to maintaining medication administration records. Please see August 10, 2023 case management report for additional information. Continued...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023
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-20230804152452
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: HOLY FAMILY HOME
FACILITY NUMBER: 347003949
VISIT DATE: 08/10/2023
NARRATIVE
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As a result of this investigation, the Department finds this allegation to be Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency cited on the LIC 9099-D, per Title 22 Regulations.

An exit interview was conducted, and a copy of the 9099 report, LIC 9099-D page, and appeal rights were given to the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 27-AS-20230804152452
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: HOLY FAMILY HOME
FACILITY NUMBER: 347003949
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/23/2023
Section Cited
CCR
87465(a)(4)
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87465(a)(4) Incidental Medical and Dental Care: A plan for incidental medical and dental care shall be developed by each facility...The licensee shall assist residents with self administered medications as needed.
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Facility staff agrees to conduct Incidental and medical and Dental training for all staff by POC date 08/23/2023. Training documents will be emailed to LPA Martinez on by POC Date 08/23/2023 by 5 PM.
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This requirement was not met as evidence by: based on interviews and file review...the Licensee did not ensure staff was following R1's new medication order for Escitalopram. This posed a potential health and safety risk for 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) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3