<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374602717
Report Date: 07/20/2023
Date Signed: 07/20/2023 02:57:41 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
07/13/2023 and conducted by Evaluator Tiffany Holmes
COMPLAINT CONTROL NUMBER: 08-AS-20230713132426
FACILITY NAME:M & M RESIDENTIALFACILITY NUMBER:
374602717
ADMINISTRATOR:JENKINS, MAKAILA AFACILITY TYPE:
735
ADDRESS:1504 WHITESTONE ROADTELEPHONE:
(619) 825-8487
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY:4CENSUS: 3DATE:
07/20/2023
UNANNOUNCEDTIME BEGAN:
10:28 AM
MET WITH:Marvasia Smith, AdministratorTIME COMPLETED:
12:25 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
`Medication log was not kept up to date
Client records were not current
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA)Tiffany Holmes conducted an unannounced complaint visit to the facility to open complaint on the above-mentioned allegations. LPA gained access to the facility, identified herself, and met with Marvasia Smith to discuss the purpose of the visit. LPA’s visit consisted of delivering findings on the above-mentioned allegation.

LPA conducted a physical inspection of the facility, collected relevant records, and conducted interviews. It was alleged that the medication log was not kept up to date Interviews revealed on July. 2, 2023 Client 1 (C1s) dose of Trazodone was missing the staffs initial, which the staff is supposed to mark off when the medication has been given. Interviews revealed the medication was given correctly but was not documented on the medication log. Outside source observations also revealed that the reasons for medications are not listed on Medication Administration Record (MAR). The medications of Trazodone and Citalopram and their dosages are not documented on the MAR or they are cut off.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023
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 3
Control Number 08-AS-20230713132426
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: M & M RESIDENTIAL
FACILITY NUMBER: 374602717
VISIT DATE: 07/20/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
It was alleged that the client records are not current. Interviews revealed the clients Individual Program Plan (IPP) was expired in the book at the facility. According to facility documents, the IPP was completed in January of 2022. Interviews revealed there is no current IPP in the clients file.

Based on the evidence obtained from interviews, records review, the complaint allegations are substantiated. An exit interview was conducted with Marvasia Smith and a copy of this report along with Licensee/Appeal Rights (LIC 9058 03/22) was provided at the conclusion of the visit.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 08-AS-20230713132426
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: M & M RESIDENTIAL
FACILITY NUMBER: 374602717
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/04/2023
Section Cited
CCR
80070(a)
1
2
3
4
5
6
7
Client Records: (a)The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client. This requirement is not met as evienced by:
1
2
3
4
5
6
7
Licensee will provide training to staff on Maintaining a MAR and medication. Trainig documents and sign in sheet will be provided to CCL by 08/04/2023
8
9
10
11
12
13
14
Based on observation, on 07/02/23, 1 of 3 clients MAR was incomplete due to not having staff intials on date medication was given. This is a potential safety risk to clients in care
8
9
10
11
12
13
14
Type B
07/28/2023
Section Cited
CCR
80068.2(1)
1
2
3
4
5
6
7
Needs and Services Plan (1)The needs appraisal or IPP is not more than one year old. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The licensee will retrieve an up to date IPP from SDRC and provide a copy to CCL by 07/28/2023..
8
9
10
11
12
13
14
Based on observation, on 07/03/23, 1 of 3 clients did not have a up to date IPP. This is a potential safety risk to clients in care
8
9
10
11
12
13
14
SDRC worker Wasson provided an up to date IPP for client by email. LPA observed IPP. Licensee corrected this on todays visit
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: 07/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3