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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604036
Report Date: 01/12/2023
Date Signed: 01/12/2023 03:26:38 PM

Substantiated


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
12/30/2022 and conducted by Evaluator Natasha Persaud
COMPLAINT CONTROL NUMBER: 08-AS-20221230164015
FACILITY NAME:BEST ELMDALE RCFFACILITY NUMBER:
374604036
ADMINISTRATOR:HILTON. JAZMINFACILITY TYPE:
735
ADDRESS:10330 ELMDALE DRTELEPHONE:
(619) 501-7785
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY:4CENSUS: 4DATE:
01/12/2023
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Staff, Enrique Bettancourt TejedaTIME COMPLETED:
01:50 PM
ALLEGATION(S):
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Facility is not maintaining client records
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit to deliver an amended report regarding the above mentioned allegation. LPA was greeted and allowed entry into the facility and met with Staff, Enrique Bettancourt Tejeda.

During the investigation, a tour of the facility was conducted, along with record review and interviews with staff, clients, and outside sources. It was alleged the facility is not maintaining client records pertaining to the MARs. C1’s has a prescribed injection they receive once every four (4) weeks. The facility does not administer the injections. C1 receives the injection at a medical facility, where the injection medication is also stored. The facility’s Medication Administration Records (MARs) for December 2022 reflected the injection was administered every day for C1. Staff interviews revealed being aware the injection is monthly and confirmed it was an error that all days were signed as dispensed. According to C1’s MARs for December 2022, C1 did not receive two (2) of their prescribed medications on 12/16/22. The back of the MAR was blank and did not indicate why the medications were not given. Continued on an LIC 9099C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
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-20221230164015
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: BEST ELMDALE RCF
FACILITY NUMBER: 374604036
VISIT DATE: 01/12/2023
NARRATIVE
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Staff interviews revealed the medication was dispensed but staff forgot to sign it, leaving it blank as though it was not dispensed. C1 confirmed receiving those prescribed medications. In addition, the medication that was not dispensed to C1 on 12/13/22, as the pill was still in the bubble pack, the MARs was signed as dispensed. The MAR was inaccurately documented by staff. Client’s medication records are not being maintained complete and current.

Based on interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 1 is being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 01/16) were provided to Staff, Enrique Bettancourt Tejeda whose signature below confirms receipt of these rights. LPA discussed the plan of correction vis telephone with the administrator.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20221230164015
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: BEST ELMDALE RCF
FACILITY NUMBER: 374604036
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/30/2023
Section Cited
CCR
80070(a)
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Client Records- The licensee shall 10-2pm Zoom. ensure that a separate, complete, and current record is maintained in the facility for each client. This requirement is not met as evidenced by:

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Administrator stated staff will attend vendorized medication training on maintaining client medication records and provide proof of training by POC due date.
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Based on interviews, the licensee did not ensure (C1) 1 out of 4 client’s medication records were being maintained complete and current. This posed a potential Health and safety risk to clients 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.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3