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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603231
Report Date: 02/06/2024
Date Signed: 04/25/2024 10:38:08 AM


Document Has Been Signed on 04/25/2024 10:38 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 03/25/2024 03:34 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management – Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with outgoing Executive Director Ashley Marcellus and Director of Resident Care Services Elizabeth Smith. LPA also met with incoming Executive Director Wesley Lavender later during the visit.

Today's visit was in response to two (2) LIC624 Incident Reports, which Licensee self-submitted to the CCLD San Diego Regional Office (both were received on 01/12/2024). According to the first LIC624: during the evening of 01/06/2024, an error by Staff #1 (S1) led to Resident #1 (R1) receiving an overdose of one (1) of their prescribed medications. [See LIC811 Confidential Names List for a description of select person identifiers used.] According to the second LIC624: during the evening of 01/09/2024, an error by S1 led to Resident #2 (R2) receiving medicine which was not prescribed to them [the medicine was instead prescribed to Resident #3 (R3)]. The above incidents did not result in any adverse health consequences to either R1 or R2.

During today’s visit, LPA briefly toured the facility and performed a welfare check on both R1 and R2, verifying that both were safe. LPA also collected copies of and reviewed pertinent care records and interviewed relevant staff.

According to their latest LIC602 Physician’s Report (dated 04/09/2019), R1 was diagnosed with Dementia, and their doctor determined that R1 required staff assistance with taking their prescribed medications. According to their latest LIC602 Physician’s Report (dated 01/24/2023), R2 was diagnosed with Mild Cognitive Impairment (MCI), and their doctor determined that they required staff assistance with taking their prescribed medications. Manager interview confirmed that both R1 and R2 were on paid medication assistance service with the Licensee during the above incidents.

[CONTINUED ON LIC 809-C, 1 of 2]

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 02/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: BELMONT VILLAGE CARDIFF
FACILITY NUMBER: 374603231
VISIT DATE: 02/06/2024
NARRATIVE
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[CONTINUED FROM LIC 809]

Staff Interviews showed: During the 01/06/2024 incident, S1 opened a pouch of medications assigned to R1 (which arrived pre-sealed from the pharmacy), then added one additional required blood thinner tablet to this pouch (as was normal process for R1), in anticipation of providing the set to R1 to ingest. However, before giving the medications to R1, S1 was called away to another task. While S1 was away, teammate Staff #2 (S2) stepped in to continue S1’s medication pass. S2 was not aware that S1 had already added one blood thinner tablet to the pouch; S2 added a second blood-thinner pill to the set, before handing all to R1 to ingest. R1 thus ingested one (1) extra dose of blood thinner medication, beyond what was prescribed to them that evening. S1 and S2 soon realized the error and notified facility management, who notified R1’s prescribing physician (PCP) and responsible person (RP) the same day. Date and time stamped progress notes, in conjunction with a review of the Medication Administrator Record (MAR) for R1, corroborated that facility withheld one of R1’s subsequent scheduled doses of the blood-thinner medication, consistent with PCP instruction. Staff continued to observe R1, who did not develop any adverse health consequence.

Staff interviews showed: During the 01/09/2024 incident, S1 was preparing/readying medications for R2 and R3 at the same time, by placing medications in each resident’s respective plastic medication cup. S1 accidentally handed R3’s cup to R2. R2 then ingested one (1) medication dose which was not prescribed to them. S1 soon realized the error and notified facility management, who notified R2’s PCP and RP the same day. The PCP did not instruct any special follow up action for R2. Staff continued to observe R2, who did not develop any adverse health consequence. Date and time stamped progress notes, in conjunction with a review of the Medication Administrator Records (MAR), corroborated that R2 still received their other prescribed medications on the evening of 01/09/2024. Also, staff took additional action to ensure that the described error with R2 did not cause a medication error for R3.

A preponderance of evidence exists to show that during the above respective incidents, process errors by Licensee’s staff (S1) resulted in R1 and R2 not receiving medications exactly as they were prescribed by their physicians.

[CONTINUED ON LIC 809-C, 2 of 2]
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: BELMONT VILLAGE CARDIFF
FACILITY NUMBER: 374603231
VISIT DATE: 02/06/2024
NARRATIVE
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[CONTINUED FROM LIC 809-C, 1 of 2]

One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the Licensee. LPA also issued one Technical Violation (TV) regarding reporting requirements (see the LIC 9102-TV page).

An exit interview was conducted with Lavender, Marcellus, and Smith, to whom a copy of this report, the LIC 809-D, the LIC9102-TV, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/25/2024 10:39 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 02/21/2024 10:27 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: BELMONT VILLAGE CARDIFF
FACILITY NUMBER: 374603231

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/06/2024
Section Cited
CCR
87465(a)(4)

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87465 Incidental Medical and Dental Care: “(a)(4) The licensee shall assist residents with self-administered medications as needed.” This requirement was not met, as evidenced by:
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Manager interviews and training/personnel records, showed: On 01/08/2024, facility management met with both S1 and S2 to verbally debrief about the 01/06/2024 incident. On 01/11/2024, facility management met with S1 to perform formal/written corrective coaching and retraining with S1, regarding both the 01/06/2024 incident and the 01/09/2024 incident. Facility management also undertook additional training with the larger medication team on 02/05/2024 and 02/06/2024. These actions resolve the deficiency.
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Based on records and interviews, the licensee did not assist 2 of 140 residents (R1 & R2) with self-administered medications as needed/prescribed, which posed a potential health risk to persons 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.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 02/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4