374602869-8-31-2022-08-AS-LTEZ-CJRRFH-20220930125911

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374602869
Report Date: 08/31/2022
Date Signed: 08/31/2022 12:56:15 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
08/16/2022 and conducted by Evaluator Dang Nguyen

COMPLAINT CONTROL NUMBER: 08-AS-20220816115653

FACILITY NAME:	CEDARS @ PARADISE VILLAGE		FACILITY NUMBER:	374602869
ADMINISTRATOR:	LAWSON, WILLIAM		FACILITY TYPE:	740
ADDRESS:	2740 E 4TH STREET		TELEPHONE:	(619) 475-5040
CITY:	NATIONAL CITY	STATE: CA	ZIP CODE:	91950
CAPACITY:	150	CENSUS: 92	DATE:	08/31/2022
		UNANNOUNCED	TIME BEGAN:	12:10 PM
MET WITH:	Executive Director Nicole Long and Resident Service Director Katrina Jimenez.		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Licensee did not give resident medication(s) as prescribed.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced subsequent visit to deliver a finding regarding the above prior complaint allegation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Nicole Long and Resident Service Director Katrina Jimenez.

It was alleged that licensee assisted Resident #1 (R1) with their normally prescribed medications, but between July 27, 2022 and July 29, 2022, two specific medications were handed to R1 in amounts less than what was specified/required by their signed physician’s order (an order which was received and acknowledged by licensee' staff on the date it was to take effect). [See attached LIC811 Confidential Names List for a description of person identifiers used in this report]. CCLD’s investigation involved interviews of pertinent residents, facility staff, and outside sources. The Department also reviewed administrative, care, and medication records from R1’s file, plus relevant E-mails and phone text message(s). [CONTINUED ON LIC 9099-C, 1 of 2]

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022

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 4

Control Number 08-AS-20220816115653

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: CEDARS @ PARADISE VILLAGE	FACILITY NUMBER: 374602869
	VISIT DATE: 08/31/2022

NARRATIVE

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[CONTINUED FROM LIC 9099]

According to interviews and facility records, R1 was diagnosed with Mild Cognitive Impairment and relied on facility staff for assistance with taking their prescribed medications. During the timeframe of the complaint allegation, R1 often attended an outpatient clinic twice per week. Based on R1’s blood tests, it was common for two specific medications to be adjusted/changed following clinic visits. On July 27, 2022, R1’s clinic physician determined that both of the said medications must now be given to R1 twice per day (instead of once per day). According to interviews of multiple outside sources, clinic staff faxed a signed valid order to the facility's nursing office, then phoned a supervisor there to confirm receipt and understanding. According to interview of Facility Supervisor #1 (S1), they received this faxed order on July 27, 2022, and told clinic staff that their team would implement the medication changes for R1 that same day. [Licensee thus had timely constructive knowledge of the orders]. According to interview of Facility Supervisor #2 (S2), they too saw the faxed order on July 27, 2022, as did S1. S1 and S2’s timely receipt was further corroborated in a phone text message between them about this specific order (the text message was date-stamped July 27, 2022).

Staff interviews revealed that this faxed order was then placed a designated basket inside the facility’s nursing office, to be entered/transcribed into the facility’s medication management software. Ultimately, however, the order was not entered into the software as was expected (rather, it was subsequently misfiled elsewhere), a fact corroborated by S1, S2, and nursing department Staff #3 (S3). R1 thus received only half of the required dosage for two of their medications for three days; the errors which were discovered when R1 returned to the outpatient clinic on July 29, 2022. These facts were corroborated in follow-up E-mails that clinic staff sent to S1. [All parties, including R1 themselves, confirmed R1 suffered no adverse health event or injury due to said error(s)]. Clinic staff immediately contacted S1 by phone and fax to correct the errors. S1 told LPA they acknowledged a mistake had occurred and apologized to the clinic staff. By July 30, 2022, facility staff had resumed giving R1 both medications according to correct/prescribed amounts. Prior to CCLD receiving the complaint, S1 independently implemented a new routing procedure within the facility’s nursing office, with the goal of preventing future medications orders being overlooked. Aside from S1, LPA interviewed three other facility staff who distribute medications; all three consistently described the new office procedure that S1 established.

[CONTINUED ON LIC 9099-C, 2 of 2]

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 08-AS-20220816115653

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: CEDARS @ PARADISE VILLAGE	FACILITY NUMBER: 374602869
	VISIT DATE: 08/31/2022

NARRATIVE

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[CONTINUED FROM LIC 9099-C, 1 of 2]

Based on interviews and records, the preponderance of evidence shows that on at least a few days, licensee did not give R1 two of their medications according to how they were prescribed. Licensee’s staff quick took action to correct and learn from the mistake, and were cooperative and forthcoming during CCLD’s investigation. The allegation, however, is substantiated. A deficiency is cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the licensee.

An exit interview was conducted with Long and Jimenez, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 01/16) were provided.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 08-AS-20220816115653

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: CEDARS @ PARADISE VILLAGE	FACILITY NUMBER: 374602869
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/31/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/30/2022 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care: “(a)(4) The licensee shall assist resident with self-administered medications as needed.” This requirement was not met, as evidenced by:	1 2 3 4 5 6 7	The Executive Director (ED) and Resident Service Director (RSD) both said that all medication orders which are entered into software (PCC) are now double verified by another nursing department staff, at least weekly. ED agreed to require: a) once per month, the RSD or the Resident Service Coordinator (RSC) will randomly select 3 medication orders and compare them against PCC, b) the auditor will immediately notify the ED of any transcription errors, and c) for any actual medication errors (in practice), they will also notify the resident’s physician and responsible party and submit an LIC624 Incident Report to CCLD. The ED agreed to codify the above in a written internal memorandum, which will indicate the new procedures’ effective date and be signed by the ED, RSD, RSC. ED agreed to E-mail a copy of the signed memorandum to LPA by the POC due date.
	8 9 10 11 12 13 14	Based on records and interviews, R1 relied on licensee for help with medications, but licensee’s staff did not hand R1 the correct/prescribed amounts for two of their medications. This posed a potential health risk to 1 of 92 residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022

LIC9099 (FAS) - (06/04)

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