374601999-12-27-2023-08-AS-JLOT-CZMUSX-20240119145101

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374601999
Report Date: 12/27/2023
Date Signed: 12/27/2023 02:51:34 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 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
01/13/2023 and conducted by Evaluator Nacole Patterson

PUBLIC

COMPLAINT CONTROL NUMBER: 08-AS-20230113113814

FACILITY NAME:	LA COSTA GOLF RCFE		FACILITY NUMBER:	374601999
ADMINISTRATOR:	JASNA POPOVICH		FACILITY TYPE:	740
ADDRESS:	2702 LA COSTA AVE		TELEPHONE:	(760) 944-1900
CITY:	CARLSBAD	STATE: CA	ZIP CODE:	92009
CAPACITY:	6	CENSUS: 5	DATE:	12/27/2023
		UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Administrator David Swagerty		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Staff dispensed medications to resident without doctors orders.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegation. LPA introduced herself and disclosed the purpose of the visit to Administrator David Swagerty.

On 1/13/23 it was alleged that staff dispensed medication without doctor's orders. The Department’s investigation consisted of unannounced facility visits, review of facility and outside source records, interviews with facility staff, residents, and outside sources. It was alleged that staff administered an over the counter medication to a resident to induce sleep. Staff interview did not corroborate the allegation, staff informed that the only medication administered to residents was ordered by resident physicians and sent to the facility from the pharmacy. Resident interviews did not corroborate the allegation, residents expressing no concerns with medication administration.

(Continued on LIC9099-C)

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Nacole Patterson	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

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-20230113113814

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: LA COSTA GOLF RCFE	FACILITY NUMBER: 374601999
	VISIT DATE: 12/27/2023

NARRATIVE

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(Continued from LIC9099)

The resident in question was unable to be interviewed. Outside source interviews were inconsistent, one source expressing minor concerns regarding medication administration due to language barriers. Other outside sources did not express concern regarding medication administration or errors. Records review revealed that the medication in question was an active prescription for the resident.

Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to conclude that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Administrator David Swagerty, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Nacole Patterson	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

LIC9099 (FAS) - (06/04)

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