374603231-8-13-2021-08-AS-DPOL-C6ES8J-20210831133913

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603231
Report Date: 08/13/2021
Date Signed: 08/13/2021 01:08:22 PM

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
02/06/2020 and conducted by Evaluator Carmen Lopez

COMPLAINT CONTROL NUMBER: 08-AS-20200206145110

FACILITY NAME:	BELMONT VILLAGE CARDIFF		FACILITY NUMBER:	374603231
ADMINISTRATOR:	SHERYL JOHNSTON		FACILITY TYPE:	740
ADDRESS:	3535 MANCHESTER AVE		TELEPHONE:	(760) 436-8900
CITY:	CARDIFF BY THE SEA	STATE: CA	ZIP CODE:	92007
CAPACITY:	175	CENSUS: 139	DATE:	08/13/2021
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Ashley Marcellus, Executive Director		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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- Staff did not administer residents medication as prescribed.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Carmen Lopez and Licensing Program Manager (LPM) Denise Powell conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegation. LPA and LPM identified themselves and was granted entry by Diana Atempa, Receptionist. LPA stated the purpose of the visit and reviewed the findings of the complaint with Executive Director, Ashley Marcellus, and Deeanna Lyons, Director of Resident Care Services.

The Department’s investigation consisted of multiple interviews with staff and outside sources, and records review of relevant documents pertinent to this investigation. On February 6, 2020, it was alleged that Resident #1 (R1) was not offered Pro Re Nata (PRN), medication as prescribed during an episode of agitation and aggressive behavior on January 29, 2020, that resulted in the Psychiatric Emergency Response Team (PERT) being called via 911.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Hedgecock	TELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Carmen Lopez	TELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021

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-20200206145110

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: BELMONT VILLAGE CARDIFF	FACILITY NUMBER: 374603231
	VISIT DATE: 08/13/2021

NARRATIVE

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Review of the LOA Medication Dosage Chart indicated the PRN medication was to be administered every six (6) hours as needed for agitation not to exceed four (4) dosages/24 hours. Per the facility’s Medication Administration Record, the PRN medication was not administered to the resident during the time R1’s episode of agitation and aggressive behavior on January 29, 2020. The “logged-in” comments entered in the MAR for January 29, 2020, indicated that R1 was OOF (out-of-facility). However, review of records established R1 was in the facility and that facility staff called 911 to assist with R1’s aggressive behavior.

Interviews with multiple staff confirmed staff did have knowledge of R1’s aggressive behavior, including agitation, and described the de-escalation process in use which involved redirecting the resident to calm down. De-escalation attempted by staff was unsuccessful and situation escalated rapidly. A review of the 911 transcripts documented that the call was initiated at 3:23 PM and there was a 33-minute window from the time of the start of the incident at approximately 2:50 PM. Interviews with multiple staff confirmed R1 was not offered or given PRN medication during the episode on January 29, 2020. A review of the R1’s Nurses Notes revealed that R1’s behavior was a pattern which staff documented knowledge of R1’s history of episodes. A similar episode occurred on December 28, 2019, which staff acted and gave R1 PRN medication and continued to monitor R1.

Based on the Department’s investigation of the above-mentioned allegation and the evidence obtained during staff and outside sources interviews and records reviewed, 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 Executive Director, Ashley Marcellus, and Deeanna Lyons, Director of Resident Care Services. A copy of this report along with Licensee/Appeal Rights (LIC9058 01/16) was provided to Executive Director, Ashley Marcellus, and Deeanna Lyons, Director of Resident Care Services via email. An electronic email receipt confirms the documents were received.

SUPERVISOR'S NAME: Rebecca Hedgecock	TELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Carmen Lopez	TELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20200206145110

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: BELMONT VILLAGE CARDIFF	FACILITY NUMBER: 374603231
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/13/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/10/2021 Section Cited CCR 87465(d)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration… this requirement was not met as evidenced by:	1 2 3 4 5 6 7	Staff training and staff in-service training documents will be submitted to assigned LPA by September 10, 2021.
	8 9 10 11 12 13 14	Based on interviews and records review, the Licensee did not assist R1 with self-administration of a PRN medication as prescribed. This posed a potential health risk to one of 139 of residents in care.	8 9 10 11 12 13 14
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	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.

SUPERVISOR'S NAME: Rebecca Hedgecock	TELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Carmen Lopez	TELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021

LIC9099 (FAS) - (06/04)

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