361880954-6-8-2023-56-AS-EMAN-CT6SBA-20230626134333

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361880954
Report Date: 06/08/2023
Date Signed: 06/08/2023 09:49:27 AM

Unsubstantiated

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 Ryan Gardner

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20221019115107

FACILITY NAME:	GRACEFUL ASSISTED LIVING		FACILITY NUMBER:	361880954
ADMINISTRATOR:	VELAZQUEZ, JESSICA		FACILITY TYPE:	740
ADDRESS:	12253 SILVER ARROW WAY		TELEPHONE:	(760) 508-2426
CITY:	VICTORVILLE	STATE: CA	ZIP CODE:	92392
CAPACITY:	6	CENSUS: 7	DATE:	06/08/2023
		UNANNOUNCED	TIME BEGAN:	08:57 AM
MET WITH:	Taryn Kelley- Caregiver		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are administering medications to residents without proper training.
Staff are preparing and administering multi-use vials without a license.
No physician orders on resident Medication Administration Records (MAR).
Staff are administering medications to residents without a physician’s order.
Staff are overusing physical and psychotropic restraints.
Residents with cognitive impairments are signing their own consent and required forms.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Ryan Gardner conducted an unannounced visit to the facility to deliver findings for the above complaint allegations. LPA met with Caregiver Taryn Kelley and explained the reason for the visit.

The investigation consisted of interviews with staff, interviews with residents, an interview with a hospice nurse, and a review of the facilities documents.

For allegation, Staff are administering medications to residents without proper training:

During interviews with staff, staff denied administering medication without proper training. The staff indicated they were trained in proper medication training.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023

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

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 56-AS-20221019115107

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: GRACEFUL ASSISTED LIVING	FACILITY NUMBER: 361880954
	VISIT DATE: 06/08/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

During document review, LPA reviewed the staff’s required forty (40) hour initial training documents. Within the training, the facility staff were trained in the proper medication procedures.

For allegation, Staff are preparing and administering multi-use vials without a license:

During interviews with staff, the staff stated they are only administering and preparing medications they are trained to administer. There are currently no residents in the facility receiving vials of medications. The last resident to receive a vial of medication was in 2021. During this time, the hospice nurse would prefill a vital of the medication and inform the staff when to administer the medication to the resident. This only took place when a resident was being provided a comfort kit during passing.

During an interview with the Hospice Registered Nurse, LPA was informed that the facility staff was trained by the hospice agency on how to administer vitals to a resident. The only time the facility staff would administer vitals to a resident was when a resident had a comfort kit for passing. The facility staff never prepared the vital medication. The hospice nurse would prefill the vitals and inform the facility staff when they could administer the medication to the resident. This process only occurs when a resident is passing, and the hospice nurse is on the way to the facility.

During document review, the residents’ hospice care plans were reviewed. LPA found that the medication that the hospice nurse informed the staff to administer was listed on the care plan.

For allegation, No physician orders on resident Medication Administration Records (MAR):

During document review, LPA reviewed the residents MAR records and hospice care plans. The MARs records and hospice care plans listed the medication orders for the residents.

For allegation, Staff are administering medications to residents without a physician’s order:

During document review, LPA reviewed the residents MAR records and hospice care plans. The MARs records and hospice care plans listed the medication orders for the residents.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 56-AS-20221019115107

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: GRACEFUL ASSISTED LIVING	FACILITY NUMBER: 361880954
	VISIT DATE: 06/08/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

For allegation, Staff are overusing physical and psychotropic restraints:

During interviews with staff, staff stated they only administer medications as directed by the physician orders and/or hospice orders. The staff denied using any type of physical restraint on the residents.

During interviews with residents, the residents denied being restrained physically and did not feel like they were being over medicated.

During document review, LPA reviewed the residents MARs records. LPA did not see any indication of the residents being over medicated.

For allegation, Residents with cognitive impairments are signing their own consent and required forms:

During interviews with staff, the staff denied having residents with cognitive impairments sign their own documents. If a resident has a cognitive impairment, their documents are signed by their responsible parties.

During interviews with residents, the residents denied signing their own documents. The residents stated that their responsible parties sign documents for them.

During document review, LPA reviewed the resident’s admissions agreements and verified their documents are signed by their responsible party.

Based on the evidence obtained during the investigation, the six (6) allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report was discussed and provided to Caregiver Taryn Kelley, along with a copy of the appeal rights.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3