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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366405771
Report Date: 12/24/2024
Date Signed: 12/24/2024 11:56:27 AM

Substantiated


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
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/03/2024 and conducted by Evaluator Bernadette Allen
COMPLAINT CONTROL NUMBER: 56-AS-20241003155326
FACILITY NAME:REST HAVEN CARE HOMEFACILITY NUMBER:
366405771
ADMINISTRATOR:REEDER, NELFAFACILITY TYPE:
740
ADDRESS:11530 ORANGE GROVETELEPHONE:
(909) 328-2569
CITY:LOMA LINDASTATE: CAZIP CODE:
92354
CAPACITY:6CENSUS: 3DATE:
12/24/2024
ANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Nelfa Reeder- AdministratorTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Facility staff do not administer resident medication as prescribed.
Facility staff do not provide adequate activities for residents in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bernadette Allen met with Licensee/Administrator Nelfa Reeder- Administrator at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office on 12/24/2024 at 11:30 AM to deliver the findings of the above allegation. LPA Allen explained the purpose of the requested office visit.

The investigation involved a review of records, and interviews with staff and responsible parties of Resident 1 (R1).

During the interview with Administrator Nelfa Reeder- Administrator, it was revealed that the facility does not maintain the MARS Medication Administration Record Schedule to show that residents' medications are being administered as prescribed by their physicians. The administrator stated that she does not keep records of when medications are given.
Additionally, when asked about activities for the clients in care, the administrator mentioned that there is no schedule for activities and that residents simply watch TV or engage in activities of their choice.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 12/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/24/2024
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-20241003155326
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
, CA 92507
FACILITY NAME: REST HAVEN CARE HOME
FACILITY NUMBER: 366405771
VISIT DATE: 12/24/2024
NARRATIVE
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The licensee was informed of her responsibility to ensure that a record is always kept to confirm that medications are dispensed as prescribed by physicians. She was also advised that daily activity schedule should be arranged for the clients in care. The absence of both the MARS schedule and organized daily activities presents a potential health and safety risk for those in care.

A citation has been issued for not having a MARS available for review and for not having a schedule for planned activities. The licensee has agreed to provide training of regulations 87465(c)(3) and 87219(a)-(i)(1) and provide training by the POC date.

Based on the evidence gathered during the investigation, the above allegation is found to be Substantiated. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted where this report was discussed and provided to Nelfa Reeder- Administrator at the conclusion of the visit with appeal rights.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20241003155326
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
, CA 92507

FACILITY NAME: REST HAVEN CARE HOME
FACILITY NUMBER: 366405771
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/03/2025
Section Cited
CCR
87465(c)(3)
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(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....(3)A record of each dose is maintained in the
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The administrator/licensee will provide LPA a copy of the MARS documenting medications administered by staff that will be used. She will also conduct training and submit a written statement of understanding of the cited regulation, signed by all staff members by January 3, 2025.
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resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.This requirement was not met as evidenced by: The administrator stated and could not provide records of medications being given to residents in care which poses a potential health, safety or personal rights risk to persons in care.
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Type B
01/03/2025
Section Cited
CCR
87219(a)-(i)(1)
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(a) -(i) (1)Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. The activities made available shall include:..This requirement was not met as evidenced by:
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The administrator/licensee will provide a copy of the monthly planned activities for residents. She will also train all staff on the cited regulation and submit a written statement of understanding, signed by all staff members assisting with activities, by January 3, 2025.
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LPA asked to review a schedule of activities that could not be provided. She said residents simply watch TV or engage in activities of their choice. The licensee has agreed to provide a written schedule of activites and will encourange residents to engage in activites daily.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 12/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/24/2024
LIC9099 (FAS) - (06/04)
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