374601258-3-6-2023-08-AS-SJAB-CPRVWU-20230309154831

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374601258
Report Date: 03/06/2023
Date Signed: 03/06/2023 10:57:50 AM

Unfounded

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
02/17/2023 and conducted by Evaluator Esther Miller

PUBLIC

COMPLAINT CONTROL NUMBER: 08-AS-20230217121136

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: 153	DATE:	03/06/2023
		UNANNOUNCED	TIME BEGAN:	09:11 AM
MET WITH:	Debbie Dala, Guest Service Manager		TIME COMPLETED:	09:54 AM

ALLEGATION(S):

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Facility staff did not administer medications as prescribed.
Facility staff did not provide assistance with medication.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Esther Miller conducted an unannounced complaint investigation visit to the facility in order to deliver findings on the above allegations. LPA was granted entry to the facility by Debbie Dala, Guest Service Manager, after identifying herself and explaining the reason for the visit.

On February 17, 2023, it was alleged that facility staff did not administer medications as prescribed and that facility staff did not provide assistance with medication, specifically for Resident 1 (R1). The Department’s investigation consisted of review of facility records and interviews of facility staff.

R1’s Admission Agreement, signed September 29, 2022, did not include medication management nor assisted living services. Facility documents also included an assessment done on September 29, 2022 that indicated that R1 was determined to be able to safely self-administer medications without

[Continued on LIC9099-C, Page 1 of 2]

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther Miller	TELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2023

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-20230217121136

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: FAIRWINDS - IVEY RANCH	FACILITY NUMBER: 374601258
	VISIT DATE: 03/06/2023

NARRATIVE

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[Continued on LIC9099, Page 2 of 2]

assistance and was considered independent. LIC602A Physician’s Report, signed on September 23, 2022 by R1’s primary care physician, indicated that R1 did not have mild cognitive impairment or dementia, that R1 could manage their own prescription medications, injections, glucose testing, PRN medications, and store their own medications.

On February 9, 2023, medical records showed that R1 was diagnosed with a contagious and infectious disease. R1 was prescribed medication that same day. On February 22, 2023, facility records revealed a fax that was sent to R1’s prescribing physician for clarification if R1 had been determined to need medication assistance as per their procedures. Interviews with staff indicated that R1 did not have a change in condition and did not need a higher level of care.

Based on the evidence obtained during the complaint investigation, the allegations that facility staff did not administer medications as prescribed and that facility staff did not provide assistance with medication is unfounded, meaning that the allegations are false, could not have happened, and/or is without a reasonable basis. Therefore, as to the above listed allegation, based on information obtained, the facility is in compliance with Title 22 regulations at this time. An exit interview was conducted with Guest Service Manager; a copy of this report and Licensee's Rights (LIC9058) were provided.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther Miller	TELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2023

LIC9099 (FAS) - (06/04)

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