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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604065
Report Date: 03/09/2022
Date Signed: 03/09/2022 08:51:56 PM



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
02/28/2022 and conducted by Evaluator Natasha Persaud
COMPLAINT CONTROL NUMBER: 08-AS-20220228171223
FACILITY NAME:LAGUNA ESTATES SENIOR LIVINGFACILITY NUMBER:
374604065
ADMINISTRATOR:DONELLE WILLIAMSFACILITY TYPE:
740
ADDRESS:1088 LAGUNA DRIVETELEPHONE:
(760) 434-7116
CITY:CARLSBADSTATE: CAZIP CODE:
92008
CAPACITY:214CENSUS: 81DATE:
03/09/2022
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Administrator, Donelle WilliamsTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff administered incorrect medication to resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced visit to commence a complaint investigation. LPA identified herself and discussed the allegation mentioned above with Administrator, Donelle Williams.

During today's visit, LPA briefly toured the facility, obtained records, and interviewed staff. It was alleged staff administered the incorrect medication to Resident #1 (R1). On 02/26/22 a Licensed Vocational Nurse (LVN) provided R1 the incorrect medication. On 02/26/22, facility increased status checks every two (2) hours to observe R1 for change in condition. No changes were observed. R1's Physician's Report reflected R1 is independent with activities of daily living and only requires medication management. On 02/27/22, staff conducted a morning status check and observed R1 found on the floor and shaking. Staff activated 911 and R1 was transported to hospital for evaluation. Staff reported the medication error to the paramedics and also notified the hospital of the error. At this time is undetermined if R1's was found on the floor due to the medication error. Continued on LIC 9099C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022
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-20220228171223
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: LAGUNA ESTATES SENIOR LIVING
FACILITY NUMBER: 374604065
VISIT DATE: 03/09/2022
NARRATIVE
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LVN self reported the incident to management. The facility immediately removed the LVN from dispensing all medications, pending internal investigation. Once the internal investigation concluded, the LVN was terminated.

An exit interview was conducted with Administrator and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided to the Administrator via electronic mail. An electronic read receipt confirmation was requested to be sent by the Administrator upon receipt of the documents.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20220228171223
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: LAGUNA ESTATES SENIOR LIVING
FACILITY NUMBER: 374604065
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/09/2022
Section Cited
CCR
87411(a)
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Personnel Requirements - General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
This requirement is not met as evidenced by:
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Administrator was proactive and medication training was completed after the incident. Administrator provided proof of training. POC corrected.
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Based on interviews and record review, the staff did not ensure R1 received the correct medication for one (1) out of 81 (eighty-one) residents. This posed a potential health and safety risk to residents 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.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3