347004960-1-18-2024-27-AS-KHOS-CZYR3P-20240130114015

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347004960
Report Date: 01/18/2024
Date Signed: 01/18/2024 03:18:23 PM

Unsubstantiated

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
12/18/2023 and conducted by Evaluator Jamie Ivey-Canady

COMPLAINT CONTROL NUMBER: 27-AS-20231218151501

FACILITY NAME:	EASTERN MANOR		FACILITY NUMBER:	347004960
ADMINISTRATOR:	APUYA, MARIA		FACILITY TYPE:	740
ADDRESS:	2629 EASTERN AVENUE		TELEPHONE:	(916) 972-9668
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95821
CAPACITY:	13	CENSUS: 11	DATE:	01/18/2024
		UNANNOUNCED	TIME BEGAN:	12:55 PM
MET WITH:	Geronima Bautista		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Staff did not provide resident's authorized representative with medication records
Staff not providing medication to resident as prescribed

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jamie Ivey Canady arrived at the facility unannounced to deliver complaint findings. LPA met with Geronima Bautista and explained the purpose of today's visit.

The investigation was conducted by the Department. The investigation consisted of interviews with staff, review of resident medical reports, facility chart notes and facility resident files.

The Department has determined the following as it relates to the allegations: Staff did not provide resident's authorized representative with medication records and Staff not providing medication to resident as prescribed.

Continued on LIC 9099 - C...
Page 1 of 2

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Jamie Ivey-Canady	TELEPHONE: (916) 862-5693
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20231218151501

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: EASTERN MANOR	FACILITY NUMBER: 347004960
	VISIT DATE: 01/18/2024

NARRATIVE

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On 12/22/2023 Licensing Program Analyst (LPA) Jamie Ivey Canady conducted interviews with facility witnesses regarding current complaint allegations. It was learned that facility staff was asked for resident medical files and medicinal prescription lists for R1. According to witness statement on 12/22/2023, a list of medications for R1 was provided to R1 physician by R1 POA. Based on interviews with facility staff, R1 POA did not provide permissions to pass along R1 medical information and provided requested documents directly to R1 physician. Therefore the allegation Staff did not provide resident's authorized representative with medication records is unsubstantiated. An unsubstantiated finding means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

On 12/22/2023, 12/26/2023 and 1/09/2024 Licensing Program Analyst (LPA) Jamie Ivey Canady conducted facility medical chart review for R1 and R2. According to medical chart review all medications are logged in accordance with Title 22 regulations. All charts are date stamped and signed by facility staff for AM and PM medications that are handed to R1 and R2. On 12/26/2023 LPA observed all facility medications for 12/26/2023 PM placed in small cups for preparation for the day's administering. Based on facility medical file review and facility resident file review, medications listed for R1 and R2 are administered as prescribed. Therefore the allegation Staff not providing medication to resident as prescribed is unsubstantiated. An unsubstantiated finding means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Per California Code of Regulations (CCRs) - Title 22 no deficiencies cited. Exit interview was held and a copy of report was given to facility administrator Geronima Bautista.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Jamie Ivey-Canady	TELEPHONE: (916) 862-5693
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024

LIC9099 (FAS) - (06/04)

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