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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374602750
Report Date: 03/02/2023
Date Signed: 03/02/2023 01:45:09 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
02/27/2023 and conducted by Evaluator Carmen Lopez
COMPLAINT CONTROL NUMBER: 08-AS-20230227111428
FACILITY NAME:ELMIRA HOME CAREFACILITY NUMBER:
374602750
ADMINISTRATOR:JENKINS, VALERIEFACILITY TYPE:
735
ADDRESS:361 ELMIRA STREETTELEPHONE:
(619) 749-9761
CITY:EL CAJONSTATE: CAZIP CODE:
92019
CAPACITY:4CENSUS: 4DATE:
03/02/2023
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Valerie Jenkins, LicenseeTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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- Staff did not administer medications as prescribed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced complaint visit to open a complaint investigation. While at the facility LPA investigated and delivered findings regarding the above-mentioned allegation. LPA identified herself and was granted entry by Valerie Jenkins, Licensee. LPA stated the purpose of the visit and reviewed the findings of the complaint with Licensee Jenkins, and House Manager Christiana Jenkins DeLeon who later arrived and joined the visit.

The Department’s investigation consisted of Licensee and House Manager interviews, records review, and LPA observations. On February 27, 2023, it was alleged that the facility was not administering medications as prescribed.

On March 2, 2023, LPA toured the facility and observed that the medications were in a locked location, the facility office, inside the medication cart. LPA conducted a review of client medications. Upon review of the medications, LPA observed that four out of four clients had missed their evening medication on March 1, 2023.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rebecca Hedgecock
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023
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-20230227111428
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: ELMIRA HOME CARE
FACILITY NUMBER: 374602750
VISIT DATE: 03/02/2023
NARRATIVE
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In addition to missed medications, LPA observed that there are PRN medications that need to be ordered or reordered for four out of four clients in care. Although a review of records show that four out of four clients took their medication, the medications were still in their bubble package. Interview with Licensee and House Manager observed the package and confirmed that the medications were missed.

Based on the Department’s investigation of the above-mentioned allegation and the evidence obtained during staff interviews, records reviewed, and LPA observations, there is sufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegation is deemed to be substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC9099D.

The report was discussed, plan of correction was jointly developed, and an exit interview was conducted with Licensee Jenkins and House Manager DeLeon. A copy of this report along with Licensee/Appeal Rights (LIC9058 3/22) was provided to Licensee Jenkins at the conclusion of the visit. The signature below confirms the receipt of these documents.
SUPERVISORS NAME: Rebecca Hedgecock
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20230227111428
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: ELMIRA HOME CARE
FACILITY NUMBER: 374602750
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/31/2023
Section Cited
CCR
80075(b)(4)
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80075 (b)(4) Health Related Services - If the client's physician has stated in writing that the client is able to determine and communicate his/her need for a prescription or nonprescription PRN medication, facility staff shall be permitted to assist the client with self-administration of their PRN medication…this requirement was not met as evidence by:
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Missing medications will be ordered and will have the pharmacy come to the facility and conduct staff training by POC due date, 3/31/23.
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Based on interviews, records reviewed, and observations, staff did not administer medications as prescribed. This posed a potential safety risk to four of four 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: Rebecca Hedgecock
LICENSING EVALUATOR NAME: Carmen Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3