361880886-10-7-2023-56-AS-NBRN-CWYV85-20231026161206

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361880886
Report Date: 02/01/2023
Date Signed: 10/07/2023 12:30:23 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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
10/19/2022 and conducted by Evaluator Amber Coleman

COMPLAINT CONTROL NUMBER: 56-AS-20221019111438

FACILITY NAME:	GARDEN OF EDEN ASSISTED LIVING		FACILITY NUMBER:	361880886
ADMINISTRATOR:	VELAZQUEZ, JESSICA A		FACILITY TYPE:	740
ADDRESS:	14383 CHAMBERLAIN DR		TELEPHONE:	(442) 242-7702
CITY:	VICTORVILLE	STATE: CA	ZIP CODE:	92394
CAPACITY:	6	CENSUS:	DATE:	02/01/2023
		UNANNOUNCED	TIME BEGAN:	01:48 PM
MET WITH:	Rosa Soto, Caregiver		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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1. Staff are preparing and administering multi-use vials without a license.
2. Staff are administering medications to residents without a physician's order.

INVESTIGATION FINDINGS:

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This unannounced visit by LPA's Amber Coleman and Amy Goldenberg is being conducted to further investigate the above mentioned complaint allegations. During the course of the investigation, interviews were conducted with staff and residents, a review of staff records, review of resident charts, and copies of the pertinent documents was obtained.

It is alleged that staff are using multiple vials to administer medications and administering medications to residents without a physician's order. LPA interviewed four, (4) employees to inquire about how medications are administered. Of 4 employees, all denied ever using the same medication vials to administer medications. All residents denied having any issues with their medications. LPA's reviewed medication cart and discovered medication errors with R1's medications and MARS. MARS revealed 16 doses on AM and 16 doses on PM. However, the bubble pack dispense indicates there are
24 doses unaccounted for. Additionally, during the review of the medication chart, LPA located a bag of unused syringes belonging to R6. R6 is former resident who passed away.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 02/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023

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 56-AS-20221019111438

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: GARDEN OF EDEN ASSISTED LIVING	FACILITY NUMBER: 361880886
	VISIT DATE: 02/01/2023

NARRATIVE

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Interview of staff 2 (S2), indicated R6 was insulin dependent and administered his own insulin. LPA review of R6's physician's report indicated that R6 was unable to manage own medications. LPA tour did not reveal any liquid Lorazapam or morphine at the facility.

We have substantiated the complaint allegations as valid and that a violation has occurred based of available evidence. A copy of this report along with appeal rights are being reviewed with, and furnished to the facility representative. Please see LIC 9099D. A copy of this report along with appeal rights are being reviewed with and furnished to the facility representative.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 02/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 56-AS-20221019111438

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: GARDEN OF EDEN ASSISTED LIVING	FACILITY NUMBER: 361880886
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/01/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/02/2023 Section Cited CCR 87629(b)(1)	1 2 3 4 5 6 7	(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensees who admit or retain residents who require injections shall be responsible for the following: (1) Ensuring that injections are administered by an appropriately skilled professional should the resident require assistance.	1 2 3 4 5 6 7	Licensee agrees to ensure that all medications are administered by a properly skilled staff member when needed. Licensee agrees to complete a LIC9098 signifying understanding of regulations cited.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by LPA observavation of bag of empty syringes inside of the Centrally Stored Medication Cart.	8 9 10 11 12 13 14
Type A 02/02/2023 Section Cited CCR 87465(c)(2)	1 2 3 4 5 6 7	(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.	1 2 3 4 5 6 7	Licensee agrees to have staff trained (herself included) by third party vendor. In addition, have the centrally stored medication cart audited by a pharmacy. Proof of completed training to be submitted to Community Care Licensing Office by plan of correction date,
	8 9 10 11 12 13 14		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: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 02/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023

LIC9099 (FAS) - (06/04)

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