361880964-3-3-2022-18-AS-NBRN-CCAQGZ-20220307111018

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361880964
Report Date: 03/03/2022
Date Signed: 03/03/2022 11:48:47 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
02/09/2022 and conducted by Evaluator Shaunte Henry

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20220209130216

FACILITY NAME:	CADENCE AT RANCHO CUCAMONGA		FACILITY NUMBER:	361880964
ADMINISTRATOR:	BAGG, JULIE		FACILITY TYPE:	740
ADDRESS:	10459 CHURCH STREET		TELEPHONE:	(480) 664-6500
CITY:	RANCHO CUCAMONGA	STATE: CA	ZIP CODE:	91730
CAPACITY:	117	CENSUS: 75	DATE:	03/03/2022
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Ben Jilbert, Memory Care Director		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff did not administer medications according to physicians orders
Staff did not notify authorized representative of change in condition
Resident missed medication

INVESTIGATION FINDINGS:

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On 3/3/22, Licensing Program Analysts (LPA)s Shaunte Henry and Ryan Garder conducted an unannounced visit for delivering the findings to the above allegations. The LPAs met with Ben Jilbert, Memory Care Director, explained the nature of the visit and was granted entry.

The investigation, which consisted of file review and interviews revealed the following:
Allegation 1: Staff did not administer medications according to physicians orders.
On 2/6/22, during a visit with Resident 1(R1), R1's family noticed that Staff 2 (S2) had prepared only one pill of Medication 2 (M2). S2 double checked the orders, retrieved the medication and provided it to R1. The Power of Attorney (POA) for R1 confirmed this information as accurate.
***Continued on 9099C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Shaunte Henry	TELEPHONE: (951) 217-0236
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022

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 18-AS-20220209130216

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: CADENCE AT RANCHO CUCAMONGA	FACILITY NUMBER: 361880964
	VISIT DATE: 03/03/2022

NARRATIVE

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*** Continued from 9099***

The LPA reviewed the Medication Administration Record (MAR) and confirmed that the medication was provided to R1. The LPA was not able to interview R1 due to being removed from the facility.

Allegation 2: Staff did not notify authorized representative of change in condition:
The complaint details indicate R1 began hallucinating on 2/6/22 after reporting that they witnessed two staff members standing in the doorway of their room. R1 was on a FaceTime call with family and the family member was able to confirm that no one was standing in the doorway. Staff 1 (S1), Staff 2 (S2), Staff 3 (S3) and Staff 4 (S4) denied witnessing R1 hallucinating. R1's file review confirms that R1 was not diagnosed with hallucination as a change of condition. The executive director confirmed that R1 did not have a change in condition. The LPA was not able to interview R1 due to being removed from the facility.

Allegation 3: Resident missed medication:
On 8/20/21, R1 noticed that Staff 4 (S4) did not have Medication 2 (M2) during the medication pass. S4 retrieved the medication and provided it to R1. The Power of Attorney (POA) for R1 confirmed this information as accurate. The LPA reviewed the Medication Administration Record (MAR) and confirmed that the medication was provided to R1. The LPA was not able to interview R1 due to being removed from the facility.

Although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore all three allegations are UNSUBSTANTIATED at this time.

An exit interview was conducted where this report and LIC 811 were provided to the executive director.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Shaunte Henry	TELEPHONE: (951) 217-0236
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022

LIC9099 (FAS) - (06/04)

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