372002165-12-28-2022-08-AS-LTEZ-CMLQHR-20221230111134

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 372002165
Report Date: 12/28/2022
Date Signed: 12/28/2022 10:04:32 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/09/2021 and conducted by Evaluator Natasha Persaud

COMPLAINT CONTROL NUMBER: 08-AS-20210209120011

FACILITY NAME:	CABANAS ADULT CARE HOME		FACILITY NUMBER:	372002165
ADMINISTRATOR:	CABANAS, ERLOVE		FACILITY TYPE:	740
ADDRESS:	8031 MONTARA AVENUE		TELEPHONE:	(858) 689-1872
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92126
CAPACITY:	0	CENSUS:	DATE:	12/28/2022
		UNANNOUNCED	TIME BEGAN:	01:04 PM
MET WITH:			TIME COMPLETED:	01:05 PM

ALLEGATION(S):

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Resident not administered medication as prescribed

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Natasha Persaud concluded the investigation regarding the above mentioned allegation. The facility was closed, and the reports were sent via certified mail.

During the investigation, a virtual tour was conducted, records requested and interviews with staff, residents, and outside sources. It was alleged Resident #1 (R1) was not administered medication as prescribed. It was reported R1 had an increase in their medication and the new medication was delivered to the facility on 01/12/21. The administrator’s interview revealed the medication was changed/increased on 01/09/21 but not received at the facility until 01/18/21. Administrator stated the changed/increased medication was dispensed to R1 on 01/18/21, once received. Administrator stated he did not receive a new Medication Administration Record (MAR) for the changed/increased medication. A review of the MARs for January 2021 reflected the original dose was dispensed to R1 for the entire month, not the increased/changed dose as prescribed. Administrator’s interview revealed R1 was administered their medication, however, it was unknown which dose was dispensed in January 2021, as the MAR reflected only the original dose dispensed. Continued on an LIC 9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha Persaud	TELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2022

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 08-AS-20210209120011

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: CABANAS ADULT CARE HOME	FACILITY NUMBER: 372002165
	VISIT DATE: 12/28/2022

NARRATIVE

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Outside source interviews revealed communication with the administrator on 01/05/21 acknowledging the increase/change of medication. Outside source interviews revealed the administrator was contacted again on 02/05/21 and appeared unaware of the increase/change. Additional outside source interviews revealed the administrator was contacted again on 02/07/21 to discuss the increased medication, which was now dispensed. R1’s interview revealed being provided the increased/changed dose but uncertain of the dates. The MARs reflected the incorrect dose was marked as dispensed. However, R1 confirms receiving the increased/changed dose. Resident interviews revealed receiving their prescribed medications.

During the course of the investigation interviews were conducted and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegation. The allegation is deemed unsubstantiated. A copy of this report was mailed certified to the licensee.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha Persaud	TELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2022

LIC9099 (FAS) - (06/04)

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