374603328-1-30-2024-08-AS-LTEZ-CZYVS7-20240130154105

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603328
Report Date: 01/29/2024
Date Signed: 01/30/2024 09:11:15 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
12/11/2023 and conducted by Evaluator Mark Mandel

COMPLAINT CONTROL NUMBER: 08-AS-20231211165614

FACILITY NAME:	ARBOR VICTORIA		FACILITY NUMBER:	374603328
ADMINISTRATOR:	RICHARD M AXTELL		FACILITY TYPE:	740
ADDRESS:	3410 HIGHLAND DRIVE		TELEPHONE:	(760) 729-4800
CITY:	CARLSBAD	STATE: CA	ZIP CODE:	92008
CAPACITY:	6	CENSUS: 6	DATE:	01/29/2024
		UNANNOUNCED	TIME BEGAN:	10:57 AM
MET WITH:	Administrator, Richard Axtell		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff did not ensure that medications were made inaccessible to residents

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Mark Mandel conducted an unannounced visit to follow-up on a complaint investigation regarding the above-mentioned allegation. LPA identified himself to, was granted entry by and met with Administrator, Richard Axtell. LPA stated the purpose of the visit and discussed the elements of the complaint with Administrator Axtell. LPA delivered the findings of the investigation that was initiated on 12/18/2023 to Adminstrator Axtell.

On 12/11/2023, the Department received a complaint alledging that facility staff did not ensure that medications were made inaccessible to residents. The Department's investigation consisted of facility visits, record reviews and interviews with residents, staff and outside sources.

During the initial visit conducted on 12/18/2023, LPA Mark Mandel and Licensing Program Manager (LPM) Simon Jacob toured the facility and interviewed staff. During the tour of the facility, LPA and LPM observed that medications for residents were kept on the second floor in a locked cabinet and the residents all lived on the first floor. Interviews revealed that Staff 1 (S1) never saw Resident 1 (R1) take any pills, but then heard R1 say that they wanted to die. LPA and LPM also observed R1 in their room lying in their bed on 12/18/2023 and their Phsycians Report confirmed that they are nonambulatory.
(Cont. on LIC9099)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Mark Mandel	TELEPHONE: 619-990-1407
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024

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 3

Control Number 08-AS-20231211165614

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ARBOR VICTORIA	FACILITY NUMBER: 374603328
	VISIT DATE: 01/29/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

(Cont. from LIC9099)

A review of the Discharge Summary from Scripps Memorial Hospital Encinitas- where R1 was taken on 12/10/2023 for 5150WI after admitting to the Carlsbad Fire Department Medics that she tried to kill herself by ingesting 2000 mg of Tylenol - states Outside Source 1 (OS1) said R1 stays in bed unless assisted by staff and can walk short distances to her bathroom, or transfer to a wheelchair, which, along with their non ambulatory status, further demonstrates R1's inability to access medication at the facility. The report also states that OS1 alleges that R1 had some Tylenol pills in a small container that was holding R1's rosary either from hoarding pills that facility staff had administered to R1 or possibly from the pills having been placed in the container prior to R1 moving into the facility. Also, the Physian's Report for R1 states they had difficulty walking, muscle weakness and were non ambulatory, which, again, points to R1's inability to access medication at the facility.

An interview with Outside Source 1 (OS1) revealed that a female caregiver- whose name they did not remember- at the facility told him by phone on 12/10/2023 that R1 had told the caregiver that they had taken 3-4 Tylenol pills. OS1 said the caregiver also told him that she saw two pills left inside of a small box that she concluded were Tylenol pills, which prompted the caregiver to call 911 in case the Tylenol R1 said they had taken would affect R1 adversely. Two or three days after the incident, OS1 visited R1 at the facility and viewed the small box where the facility caregiver said she had found the Tylenol pills and confirmed he had seen the box previously, but did not think it ever contained any medication and he had never opened it. OS1 said the box was white in color and had a religious picture on it and had a rosary inside of it. He said the box was really for religious items and R1 is "pretty religious". OS1 said he did not bring any medication to R1 at the facility and that R1 has no opportunity to access medication when he takes them to the doctors or from anywhere, but said the Tylenol pills could have been in the box prior to the date R1 moved into the facility and maybe for years, or R1 may have been hoarding pills given to them by staff. OS1 said R1 was living in their own home as recently as August 2023, but then they fell and went to the hospital. Once R1 left the hospital they went to Vista Life Care for two to three weeks and then they were admitted to Arbor Victoria in September 2023. He added that R1's medication is kept in another room at the facility in a drawer or cabinet and it is administered to R1 by staff who put it in R1's hand, while giving R1 a cup of water to drink with their medication.

(Cont. on LIC9099)

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Mark Mandel	TELEPHONE: 619-990-1407
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 08-AS-20231211165614

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ARBOR VICTORIA	FACILITY NUMBER: 374603328
	VISIT DATE: 01/29/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

(Cont. from LIC9099)

Also, Carlsbad Police Department Report No. 2307923.1 states that the facility administrator told the responding officer that R1 had been hiding a stash of Tylenol in their room, which corroborates a similar statement made by OS1 to the doctor at Scripps Memorial Hospital Encinitas that discharged R1 on 12/12/2023, and one made to LPA Mandel by OS1.

LPA also reviewed the House Rules staging it is not appropriate for residents to refuse to store prescribed and over-the-counter medications in a secured locked central location. The form was signed by OS1.

During today's visit, LPA toured the facility, reviewed records, observed residents in care and interviewed staff, residents and outside sources. S1 stated he spoke to OS2 on 12/24/2023 and she told him she did give R1 Tylenol pills that OS2 bought at Costco when R1 was her neighbor in Oceanside and also told S1 that R1 kept the Tylenol pills in a pill box designed to hold a rosary. LPA also spoke to OS2 and she confirmed that she gave R1 Tylenol pills when R1 lived in Oceanside that OS2 had bought as Costco. OS2 said R1 kept the Tylennol in a pill box the was round and gold in color and held six pills. OS2 said she never gave any pills to R1 during anytime she visited R1 at the facility, which she said is 3-4 times weekly. OS2 said it is possible that R1 brought the pills OS2 gave her when they both were neighbors in Oceanside to the facility, but she was not aware of it if she did. She added that R1 doesn't have access to medication and can't get up to get in any drawers.

LPA confirmed daily medication is locked up in a drawer in the kitchen and that a storage of medication for the month is kept locked in a desk upstairs.

Based on the interviews conducted and records obtained and reviewed, the allegation that facility staff did not ensure that medications were made inaccessible to residents is Unsubstantiated, as the preponderance of evidence standard was not met. An exit interview was conducted with Administrator, Richard Axtell, and a copy of this report was provided to Administrator Axtell.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Mark Mandel	TELEPHONE: 619-990-1407
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 3