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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374601153
Report Date: 04/19/2023
Date Signed: 04/19/2023 04:19:39 PM

Substantiated


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
04/16/2021 and conducted by Evaluator Tiffany Holmes
COMPLAINT CONTROL NUMBER: 08-AS-20210416133441
FACILITY NAME:GRANADA HILLSFACILITY NUMBER:
374601153
ADMINISTRATOR:KATHY NELSONFACILITY TYPE:
735
ADDRESS:3990 N. GRANADA AVENUETELEPHONE:
(619) 660-0416
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY:6CENSUS: 6DATE:
04/19/2023
UNANNOUNCEDTIME BEGAN:
02:32 PM
MET WITH:Kathy Nelson, AdministratorTIME COMPLETED:
02:50 PM
ALLEGATION(S):
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Facility staff mismanaged clients' medication
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA)Tiffany Holmes conducted an unannounced complaint visit to the facility to deliver findings on the above-mentioned allegation. LPA gained access to the facility, identified herself, and met with Kathy Nelson, Administrator to discuss the purpose of the visit. LPA conducted interviews, made observations, and obtained and reviewed pertinent records. It was alleged that facility staff mismanaged clients' medication. Interviews revealed that on April.12, 2021, Client 1 (C1) was given the wrong injection by the staff. Interviews revealed the staff put down the intended injection for C1 when C1 swung at them. Staff then picked up the incorrect injection (Enbrel) and gave it to C1. Interviews revealed the error was caught immediately, staff called the the doctor and they were advsied to still give C1 the correct injection. Based on the evidence obtained from interviews, and records review, the complaint allegation is substantiated.
An exit interview was conducted with Kathy Nelson and a copy of this report along with\ Licensee/Appeal Rights (LIC 9058 03/22) was provided at the conclusion of the visit.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2023
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 2
Control Number 08-AS-20210416133441
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: GRANADA HILLS
FACILITY NUMBER: 374601153
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/28/2023
Section Cited
CCR
80075(b)(5)(B)
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Medications shall be given according to physician's direction. This requirement has not been met as evidenced by:
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The licensee had staff retrained and provided proof of training to SDRC.Licensee will provide training to all staff and POC to dept by 04/28/2023 to iclude training documents and sign in sheet.
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Based on documentation, the licensee failed to ensure 1 out of 6 clients received the correct prescribed medication. On 04/12/21staff gave C1 the wrong medication. This is an immediate health & safety risk to clients in care.
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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: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2023
LIC9099 (FAS) - (06/04)
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