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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604122
Report Date: 04/29/2022
Date Signed: 04/29/2022 11:43:33 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,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/24/2021 and conducted by Evaluator Liliana Silveira
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20210524113954
FACILITY NAME:MERAKEY COLTRANEFACILITY NUMBER:
374604122
ADMINISTRATOR:ROQUEMORE, CARLYFACILITY TYPE:
737
ADDRESS:1927 COLTRANE PLTELEPHONE:
(442) 286-7428
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY:4CENSUS: 4DATE:
04/29/2022
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Lead 2 Matthew RobinsonTIME COMPLETED:
11:10 AM
ALLEGATION(S):
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Facility staff did not administer medication as prescribed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Liliana Silveira conducted a complaint investigation visit to deliver findings for the above allegation. LPA Silveira met with Lead 2 Matthew Robinson and shared the findings.

The Department’s investigation consisted of interviews and records review. On 05/24/21 it was alleged that facility staff did not administer medication as prescribed. The alleged incident occurred on 05/18/21 with client #1 (C1). Records review revealed that a time change for administration of a prescribed medication was approved by C1’s primary care provider on 05/10/21. Records review also confirmed that the newly approved medication times were updated on the Medication Administration Record (MAR) on 05/18/21. Interviews with the facility Licensed Vocational Nurse (LVN) and the Administrator acknowledged that even though the MAR had been updated, the medication was not given to C1 by staff #1 (S1) on 05/18/21 for 1 out of the 3 prescribed times. Interviews indicated that staff #1 (S1) still followed the older prescription for times the medication should have been administered.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Liliana Silveira
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022
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-20210524113954
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: MERAKEY COLTRANE
FACILITY NUMBER: 374604122
VISIT DATE: 04/29/2022
NARRATIVE
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Based on the evidence obtained from the complaint investigation, the allegation that facility staff did not administer medication as prescribed is found to be SUBSTANTIATED, as there is a preponderance of evidence to show that the allegation occurred. Pursuant to the California Code of Regulations, Title 22, Division 6, deficiency is being cited on the attached LIC 9099D.

An exit interview was conducted, plan of correction was developed and a copy of this report and Licensee's Rights (9058 01/16) were provided to Lead 2 Matthew Robinson at the facility.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Liliana Silveira
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20210524113954
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: MERAKEY COLTRANE
FACILITY NUMBER: 374604122
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/29/2022
Section Cited
CCR
80075(b)(5)(B)
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80075 Health Related Services (b) clients shall be assisted as needed with self-administration of prescription and nonprescription medications...(B) once ordered by the physician the medication is given according to the physician's direction.
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Effective immediately, all staff were retrained on medication management. A Buddy System was also implemented, where a staff member reviews medications and MAR 30 minutes after medications have been administered to ensure none have been missed.

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This requirement was not met as evidenced by: Based on interviews and records review, the licensee did not ensure medication was given as prescribed for one client. This posed a potential health risk to one of four 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: Denise Powell
LICENSING EVALUATOR NAME: Liliana Silveira
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3