374603596-5-20-2022-08-AS-DPOL-CEXVMX-20220531163414

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603596
Report Date: 05/20/2022
Date Signed: 05/20/2022 05:35:17 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, 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
09/29/2021 and conducted by Evaluator Marisela Garcia-Centeno

COMPLAINT CONTROL NUMBER: 08-AS-20210929160539

FACILITY NAME:	PEOPLE'S CARE JOHNSON LAKE		FACILITY NUMBER:	374603596
ADMINISTRATOR:	PERONA REYES, LISA		FACILITY TYPE:	735
ADDRESS:	11691 JOHNSON LAKE DR		TELEPHONE:	(619) 390-1380
CITY:	LAKESIDE	STATE: CA	ZIP CODE:	92040
CAPACITY:	4	CENSUS: 4	DATE:	05/20/2022
		UNANNOUNCED	TIME BEGAN:	02:50 PM
MET WITH:	Administrator, Sysvia Davalos		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff did not administer residents medications as prescribed

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced visit to deliver investigative finding in response to the above listed complaint allegation. LPA was granted entry into the facility and met with Sylvia Davalos, Administrator, to whom she explained the reason for the visit.

Community Care Licensing (CCL) has investigated the above listed allegation. The investigation consisted of reviews of records maintained by the facility and interviews of residents, staff, and outside sources.

On September 29, 2021, it was alleged that on September 19, 2021, Staff (S1) did not administer medication as prescribed to Clients (C1) and (C2). [Administrator was provided an LIC 811 Confidential Names List that identifies S1 and C1 and C2]. It was specifically alleged that S1 administered medication to C2 two hours after it was due. It was also alleged that S1 administered three of the seven required daily medications to C2 three hours after they were due. The complaint allegation indicated that S1 was made aware of the medication errors and that S1 provided the medication late without following up with the pharmacy or primary care physician to get instructions on how to administer the missed medications.
continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022

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-20210929160539

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: PEOPLE'S CARE JOHNSON LAKE	FACILITY NUMBER: 374603596
	VISIT DATE: 05/20/2022

NARRATIVE

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Details of which medications were missed were not provided or obtained during the investigation.

Based on interviews and Medication Administration Records (MARs) review, there was insufficient evidence to support the allegation. Review of the MARs from August 1, 2021 to October 8, 2021 for C1 and C2 was documented and initialed as being administered as prescribed. Specifically, on September 19, 2021 all medication entries on the MARs showed no medication errors documented for C1 and C2. Staff and outside sources consistently denied knowing of any medication administration errors for C1 or C2. Specifically, S1 denied the allegation. LPA was able to determine during the course of the investigation that staff received required annual training on medication administration including S1. Interviews with staff consistently confirmed all staff including S1 were knowledgeable of the correct protocols to follow when medication errors occurred. No exceptions to these protocols were disclosed or discovered during the investigation. No third-party concerns regarding medications were received during the time frame of September - October 2021 and there was no indication of any adverse outcomes to clients.

Based upon a lack of evidence that facility staff did not administer medications as prescribed, the allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

An exit interview was conducted, and a copy of this report was provided to Administrator, Davalos at the conclusion of the visit. Davalos was provided a copy of Licensee Appeal Rights (LIC 9058), and her signature on this report acknowledges receipt of copies of the rights and the report.

SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022

LIC9099 (FAS) - (06/04)

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