374601258-5-29-2024-08-AS-JLOT-D5STZE-20240531151012

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374601258
Report Date: 05/29/2024
Date Signed: 05/29/2024 10:51:26 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
11/17/2023 and conducted by Evaluator Rebecca A Ruiz

COMPLAINT CONTROL NUMBER: 08-AS-20231117104930

FACILITY NAME:	FAIRWINDS - IVEY RANCH		FACILITY NUMBER:	374601258
ADMINISTRATOR:	SOMMER, JESSICA		FACILITY TYPE:	740
ADDRESS:	4490 MESA DR		TELEPHONE:	(760) 439-8090
CITY:	OCEANSIDE	STATE: CA	ZIP CODE:	92056
CAPACITY:	200	CENSUS: 165	DATE:	05/29/2024
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	General Manager Karl Miller		TIME COMPLETED:	10:50 AM

ALLEGATION(S):

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Facility staff did not ensure that medications were made inaccessible to residents, resulting in hospitalization

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced complaint visit to conduct follow-up and deliver findings regarding the above-mentioned allegation. LPA identified herself to, was greeted by, and explained the purpose of the visit to General Manager Karl Miller.

During today's visit, LPA observed residents in care, reviewed facility records, and spoke to staff.

The Department’s investigation consisted of interviews with residents, staff, and outside sources, records review, and a tour of the facility. It was alleged that facility staff did not ensure that medications were made inaccessible to residents, resulting in the hospitalization of Resident 1 (R1). Interviews with staff and outside sources and review of assessment records dated November 2022 revealed that R1 was not diagnosed with any cognitive impairment, was able to leave the facility unassisted, was not confused or disoriented, was able to follow directions and make their needs known, and was able to administer and store their own medications. Continued on LIC9099-C page…

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024

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-20231117104930

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: FAIRWINDS - IVEY RANCH	FACILITY NUMBER: 374601258
	VISIT DATE: 05/29/2024

NARRATIVE

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Interviews and review of communications between the facility and R1’s physician revealed that R1 was approved to self-administer and store multiple medications, including Temazepam. Interviews and medication orders revealed that R1 was approved to self-administer Temazepam until November 10th, 2023, and that facility staff began administering R1’s Temazepam on November 10^th, 2023. Interviews with staff and outside sources revealed that after R2’s eviction, R1 was relocated to another apartment within the facility. During the move, staff searched R1’s apartment for any medications and located several medication bottles which were entered into the facility’s central medication storage, including a bottle of Temazepam. Interviews with staff and outside sources revealed that prior to November 10^th, 2023, R1 was permitted to reorder medications and it was possible that R1 had ordered an additional bottle of Temazepam that staff were not aware of and had not found during R1’s move to a different apartment. Additionally, R1’s prescription for Temazepam was written to be administered as needed, which allowed for the possibility for R1 to have multiple bottles of the medication if R1 ordered new bottles monthly, which R1 was approved to do. Interviews with staff and outside sources did not reveal concerns that staff had intentionally neglected to collect all medications from R1’s possession once R1 was no longer approved to self-administer and R2 had a history of hiding R1’s medications while R2 was living with R1.

The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of the evidence has not been met, therefore, this allegation is deemed unsubstantiated.

An exit interview was conducted with General Manager Karl Miller, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20231117104930

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: FAIRWINDS - IVEY RANCH	FACILITY NUMBER: 374601258
	VISIT DATE: 05/29/2024

NARRATIVE

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Review of multiple communications between R1’s physician and the facility during 2023 revealed that R1 was approved to self-administer their medications. Review of reports submitted to the Department by the facility revealed that on November 15^th, 2023, R1 was hospitalized due to a suspected medication overdose. Facility generated reports and interviews with staff and outside sources revealed that at around 9:40am, R1 refused to take their medications and made suicidal comments to Staff 1 (S1). S1 questioned R1 regarding the comments but R1 did not provide any additional information. S1 informed the Health and Wellness Director (HWD) verbally, R1’s son via telephone, and R1’s physician via fax directly following the interaction with R1, and placed R1 on hourly safety checks. Interviews with S1 revealed that while R1 was placed on hourly checks, S1 visually observed R1 at around 10:00am and 10:15am during additional attempts to give R1 their medications, which R1 refused both times. At around 10:40am, R1’s son arrived at the facility and voiced concerns that R1 was not answering the telephone. Interviews with R1’s son revealed that upon entering R1’s room, R1 was observed to be non-responsive. R1’s son activated the emergency pull cord and S1 and another staff arrived promptly. Interviews did not provide clear information on if R1’s son or facility staff called 911, but interviews did confirm that 911 was contacted at around 10:45am for R1’s condition. R1 was transported to the hospital and admitted around 11:40am. While at the hospital, R1 received treatment for a medication overdose of Temazepam. R1 was discharged from the hospital and returned to the facility 10 days later, on November 25^th, 2023.

Interviews with staff and outside sources revealed that R1 was in a relationship with another resident, Resident 2 (R2) prior to living at the facility and they had moved into the facility together. Interviews with staff and outside sources revealed that R2 assisted R1 in medication management and storage and would occasionally accompany R1 to medical appointments. Staff and outside sources described R2 as having episodes of verbal and physical aggression towards R1 and had controlling behaviors regarding R1’s medications. R2 had a history of hiding and preventing R1 from taking prescribed medications. Interviews revealed that R2 was evicted from the facility due to R2’s aggression towards R1 approximately one month prior to R1’s medication overdose on November 15^th, 2023. Staff expressed beliefs during interviews that R1 experienced some confusion and difficulty with adapting to R2’s absence after R2’s eviction.

Continued on LIC9099-C page…

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024

LIC9099 (FAS) - (06/04)

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