347005512-10-11-2022-27-AS-KHOS-CKCSTZ-20221019141021

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347005512
Report Date: 10/11/2022
Date Signed: 10/11/2022 03:17:48 PM

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
06/09/2022 and conducted by Evaluator Jamie Ivey-Canady

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20220609110321

FACILITY NAME:	ELK GROVE PARK ASST. LVG AND MEMORY CARE COMMUNITY		FACILITY NUMBER:	347005512
ADMINISTRATOR:	JAMES HALL		FACILITY TYPE:	740
ADDRESS:	6727 LAGUNA PARK DR		TELEPHONE:	(916) 683-1881
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95758
CAPACITY:	108	CENSUS: 52	DATE:	10/11/2022
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	James Hall		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Staff are not dispensing medication as prescribed

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jamie Ivey Canady arrived at the facility unannounced to deliver complaint investigation findings. LPA Ivey Canady explained the purpose of the visit and was met by James Hall.

The investigation was conducted by LPA Ivey Canady. The investigation consisted of interviews with staff, reporting party, other witnesses, review of resident files and caregiver daily notes.

The Department has determined the following as it relates to the allegations: Staff are not dispensing medications as prescribed.

Continued on LIC 9099 - C...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-Canady	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022

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-20220609110321

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: ELK GROVE PARK ASST. LVG AND MEMORY CARE COMMUNITY	FACILITY NUMBER: 347005512
	VISIT DATE: 10/11/2022

NARRATIVE

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According to interviews with staff, residents and document reviews, S1 dispensed medication to R1 that was a greater milligram strength that had been prescribed by a healthcare professional. According to staff reports, R1 was monitored closely for any alarming side effects after being given the wrong dosage and S1 was removed from the position of being able to dispense medication.

Furthermore, based on witness interviews and documentation received, resident prescriptions were not being filled in a timely manner. Based on documentation review, during the period of time including May 2022 to present, there were instances that medication was not being dispensed because the prescribed refills had not taken place in time for resident’s regular medication regimen to be consistent.

Based on interviews and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8) are being cited on the attached LIC-9099D. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided.

An exit interview was conducted, and a copy of the report was provided to James Hall .

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-Canady	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20220609110321

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: ELK GROVE PARK ASST. LVG AND MEMORY CARE COMMUNITY	FACILITY NUMBER: 347005512
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/11/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/11/2022 Section Cited CCR 80075(b)(5)(B)	1 2 3 4 5 6 7	80075(b)(5)(B)Health Related Services (b) Clients shall be assisted as needed with self-administration...(5) If the client's physician has stated in writing that the client is unable to determine...(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	The licensee stated the staff that were involved in the med error are no longer with community and community wellness director on site will provide in service training to med techs on expectations regarding centrally stored medication and maintaining medication on site per doctors orders. Licensee will provide LPA with training documentation by COB 10/12/2022.
	8 9 10 11 12 13 14	Based on interviews and record review, the licensee did not ensure residents medication was dispensed as prescribed. This poses a potential 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: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-Canady	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022

LIC9099 (FAS) - (06/04)

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