361880835-10-4-2021-18-AS-DMUN-C87RTS-20211027131846

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361880835
Report Date: 10/04/2021
Date Signed: 10/04/2021 11:01:31 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/28/2020 and conducted by Evaluator Stephanie Torres

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200228161853

FACILITY NAME:	VISTA BLUE MOUNTAIN		FACILITY NUMBER:	361880835
ADMINISTRATOR:	TRABUCCO, MEGAN		FACILITY TYPE:	740
ADDRESS:	22325 BARTON ROAD		TELEPHONE:	(909) 420-0153
CITY:	GRAND TERRACE	STATE: CA	ZIP CODE:	92313
CAPACITY:	150	CENSUS: 79	DATE:	10/04/2021
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Raj Thandi, Corporate Director		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Facility staff failed to administer medication to resident as prescribed.
Medications are not refilled in a timely manner

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to deliver the findings of the investigation into the above allegations. The LPA met with Business Office Manager (BOM) Mayra Perez, and later spoke with Corporate Director, Raj Thandi, via telephone call. Perez and Thandi were informed of the purpose of the visit.

Regarding the allegation, "Facility staff failed to administer medication to resident as prescribed," it was alleged facility staff failed to administer one (1) medication to Resident One (R1) as prescribed by their physician. The LPA initiated the investigation on March 05, 2020; staff interviews were conducted, records were reviewed, and copies of pertinent information were obtained. Of the five (5) staff interviews conducted, each indicated R1 was not administered one (1) of their medications for several weeks. R1's Medication Administration Record (MAR) revealed one (1) medication was not administered for fifteen (15) days in the month of January 2020 nor for twenty-five (25) days in the month of February 2020. According to R1's medication list and interviews, the medication was ordered to be dispensed daily. This posed an immediate threat to the health of the resident in

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Reyna Lacey	TELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2021

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 18-AS-20200228161853

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: VISTA BLUE MOUNTAIN	FACILITY NUMBER: 361880835
	VISIT DATE: 10/04/2021

NARRATIVE

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care. Therefore, based on interviews, this allegation is deemed SUBSTANTIATED.

Pertaining to the allegation, "Medications are not refilled in a timely manner," it was alleged facility staff failed to ensure one (1) medication was refilled for R1, leading to the unavailability of the medication from January 14, 2020 through February 27, 2020. Interviews and R1's MAR reveal one (1) medication for R1 was not administered from 01/14/20 through 02/27/20. Interviews revealed the medication was not administered due to there being no available refill. Additionally, interviews revealed refills were being requested by facility staff from R1's pharmacy, without success; however, documentation for such attempts was not observed. This posed an immediate threat to the health of the resident in care. Therefore, this allegation is deemed SUBSTANTIATED.

A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Citations will be issued in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8).

An exit interview was conducted with Corporate Director, Raj, in which this report was reviewed and a copy was provided. Raj permitted BOM Perez to sign the report.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2021

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20200228161853

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: VISTA BLUE MOUNTAIN	FACILITY NUMBER: 361880835
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/04/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/08/2021 Section Cited CCR 87465(c)(2)	1 2 3 4 5 6 7	Incidental Medical & Dental Care: If the resident's physician has stated...he/she is unable to determine their...need for nonprescription PRN meds but can communicate their symptoms..., designated staff are permitted to assist...provided all of the following are met: Once ordered by the	1 2 3 4 5 6 7	The Corporate Director stated proof of in-service training with regard to medication administration will be provided to the Department by POC due date.
	8 9 10 11 12 13 14	physician the meds are given according to...directions. This requirement wasn't met as evidenced by: Based on observation & interviews, the Licensee didn't ensure R1's med. was given as directed. A MAR shows 1 daily med not given to R1 for 15 days in January nor for 27 days in February.	8 9 10 11 12 13 14
Type B 10/08/2021 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	Personnel Requirements - General: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs…This requirement was not met as evidenced by: Based on interviews, the Licensee did not ensure staff were competent to provide R1	1 2 3 4 5 6 7	The Corporate Director stated proof of in-service training with regard to refills will be provided to the Department by POC due date.
	8 9 10 11 12 13 14	w/ the services necessary to meet their needs. Interviews & R1's MAR reveal 1 of their med. was not administered. Interviews revealed the med. was not administered due to no available refill. It was revealed that refills were being requested by staff, without success; however, documentation was not observed.	8 9 10 11 12 13 14

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: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2021

LIC9099 (FAS) - (06/04)

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