347005512-5-25-2023-27-AS-KHOS-CSCMX9-20230531095934

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347005512
Report Date: 05/25/2023
Date Signed: 05/25/2023 02:37:33 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 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
02/22/2023 and conducted by Evaluator Vincent Moleski

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20230222131123

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: 43	DATE:	05/25/2023
		UNANNOUNCED	TIME BEGAN:	02:10 PM
MET WITH:	Morgan Whinery		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Facility staff mishandling resident’s medication.

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 administrator Morgan Whinery and explained the purpose of the visit.

This investigation consisted of interviews with three staff members, (S1-S3), interviews with administrator Whinery, and review of resident records for R1.

LPA Moleski reviewed three signed doctor’s orders regarding a prescribed medication for R1. LPA Moleski observed signed doctor’s orders for R1 dated September 2, 2022, ordering R1 to take one half tablet of this medication daily. LPA Moleski observed signed doctor’s orders dated October 4, 2022, ordering R1’s dosage of medication be reduced to one half tablet taken every other day.

[Continued on 9099-C]

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent Moleski	TELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023

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-20230222131123

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 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: 05/25/2023

NARRATIVE

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LPA Moleski observed doctor’s orders dated February 22, 2023, ordering R1’s prescription be discontinued. The latest of these doctor’s orders indicate the dosage of this medication was one half tablet to be taken every other day.

LPA Moleski reviewed R1’s MARs for the months of September 2022 through February 2023. R1 received a daily dose of this medication during the month of September 2022 through the first several days of October 2022. Starting on October 6, 2022 and lasting through October 25, 2022, R1 received doses of this medication every other day. Beginning on October 27, 2022, and lasting through February 15, 2023, R1 regularly received a daily dose of this medication.

Whinery was unable to provide LPA Moleski any doctor’s orders justifying the increase in dosage in late October.

The department has determined the following as it relates to the allegation that facility staff are mishandling a resident’s medication:

Based on review of R1’s MARs and doctor’s orders, and based on interviews with Whinery, R1’s medication was increased without having a physician’s authorization on file. Therefore, 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 being cited per 22 CCR Section 87465(a)(5)(A).

An exit interview was held with Whinery. Appeal rights and a copy of this report were left with Whinery.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent Moleski	TELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20230222131123

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 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: 05/25/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/26/2023 Section Cited CCR 87465(a)(5)(A)	1 2 3 4 5 6 7	22 CCR Section 87465(a)(5)(A) – Incidental Medical and Dental Services: “(5) … Assistance with self-administered medications shall be limited to the following: (A) Medications usually prescribed for self-administration which have been authorized by the person's physician.” This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee previously conducted training regarding proper medication procedures. LPA Moleski received a copy of this training on May 11, 2023.
	8 9 10 11 12 13 14	Based on review of R1’s MARs showing an increase of dosage on October 27, 2022, and based on interviews with administrator Morgan Whinery in which she stated that she could not find a doctor’s order to account for the increase, dosages of this prescribed medication were increased without proper authorization from R1’s physician.	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: Vincent Moleski	TELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023

LIC9099 (FAS) - (06/04)

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