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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604036
Report Date: 06/06/2023
Date Signed: 06/06/2023 11:31:13 AM

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
06/01/2023 and conducted by Evaluator Tiffany Holmes
COMPLAINT CONTROL NUMBER: 08-AS-20230601142456
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:
06/06/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Angela, Office Assistant &
Celina Brown, Administrator		TIME COMPLETED:
11:35 AM
ALLEGATION(S):
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Facility is not maintaining client records
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Tiffany Holmes conducted an unannounced visit to open a complaint regarding the above mentioned allegations. LPA was greeted and allowed entry into the facility and met with Angela, Office Assistant. Celina Brown, Administrator and Jazmin Hilton, Licensee arrvied during the visit.

During the investigation, a tour of the facility was conducted, along with record review and interviews with staff, and outside sources.

It was alleged the facility is not maintaining client records. Interviews revealed that pertaining to the Medication Administration Record (MAR) the staff did not mark the MAR stating the medication was given to Client 1 (C1) although interviews revealed the client received their medication.

Staff interviews revealed the medication was dispensed to C1 but staff forgot to sign the MAR, leaving it blank as though it was not dispensed. Interviews with SDRC worker confirmed that the client received the medication and that staff just did not write it down. LPA observation shows the MARs documented for the date and was signed in front of SDRC worker the day of the medication being dispensed.


Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2023
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-20230601142456
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: 06/06/2023
NARRATIVE
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In addition, the medication that was dispensed to C1 on 05/17/2023, was observed to not be in the bubble pack. Client’s medication records are not being maintained complete and current.

Based on interviews with staff and outside sources and a record review, 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 Celina Brown, Administrator whose signature below confirms receipt of these rights.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20230601142456
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: 06/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/16/2023
Section Cited
CCR
80070(a)
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Client Records- The licensee shall 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 a vendorized training on maintaining client medication records. Staff will provide proof of training and training documents aliong with sign in sheet to CCL by POC due date of 06/16/2023
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Based on interviews, the licensee did not ensure that 1 out of 4 client’s medication records were being maintained complete and current for C1. This posed a potential Health and safety risk to clients in care.
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Administrator will have training on June 14, 2023 at 11am for all staff with Medicine Care Pharmacy.
Type B
CCR
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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: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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