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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603269
Report Date: 04/23/2024
Date Signed: 04/23/2024 10:18:25 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/26/2021 and conducted by Evaluator Amy Domingo
COMPLAINT CONTROL NUMBER: 08-AS-20210826140810
FACILITY NAME:NALAS RES.FAC. JACLYN'S HOMEFACILITY NUMBER:
374603269
ADMINISTRATOR:HUBER BARQUEROFACILITY TYPE:
735
ADDRESS:276 N WISCONSIN STTELEPHONE:
(760) 728-2671
CITY:FALLBROOKSTATE: CAZIP CODE:
92028
CAPACITY:4CENSUS: 3DATE:
04/23/2024
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Jayme Covarrubias, Support Staff TIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff administered medications not prescribed by a physician.
Staff overmedicated client
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to deliver findings regarding the above complaint allegation. LPA introduced herself and disclosed the purpose of the visit to Support Staff Jayme Covarrubias.

On 8/26/2021 it was alleged that facility staff administered medication not prescribed by a physician to Resident and staff overmedicated resident. The Department’s investigation consisted of unannounced facility visits, review of facility records and interviews with outside sources and facility staff.

Staff interview revealed that the medication in question was prescribed to be given as needed when R1 presented outside of R1's baseline behaviors. Staff interview revealed that staff were in communication with R1's physician and Conservator regarding the administration of the medication. Records review revealed daily documentation by staff regarding R1's behaviors and when the medication was given.

Continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024
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 2
Control Number 08-AS-20210826140810
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: NALAS RES.FAC. JACLYN'S HOME
FACILITY NUMBER: 374603269
VISIT DATE: 04/23/2024
NARRATIVE
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Continued from LIC9099

Records review did not give evidence to the medication being administered to R1 when it was not needed or outside of the prescription.  Records review corroborated that staff were in communication with R1's physician, and Conservator regarding R1's medication regimen.  Outside sources did not respond for interview. 

Based on interviews and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED.  An exit interview was conducted with Support Staff Jayme Covarrubias to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2