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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604188
Report Date: 01/11/2023
Date Signed: 01/11/2023 04:59:55 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
01/05/2023 and conducted by Evaluator Dawn Segura
COMPLAINT CONTROL NUMBER: 08-AS-20230105135624
FACILITY NAME:R&A HOMESFACILITY NUMBER:
374604188
ADMINISTRATOR:SAMS, ROSEFACILITY TYPE:
735
ADDRESS:1670 BAKERSFIELD STTELEPHONE:
(619) 962-8009
CITY:LEMON GROVESTATE: CAZIP CODE:
91945
CAPACITY:4CENSUS: 4DATE:
01/11/2023
UNANNOUNCEDTIME BEGAN:
01:23 PM
MET WITH:Lelani Sams, StaffTIME COMPLETED:
02:50 PM
ALLEGATION(S):
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Facility staff pre-poured client medications.

Licensee did not maintain accurate medication administration records.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Dawn Segura conducted an unannounced visit to commence an investigation into the above listed complaint allegations. After introducing herself, LPA was granted entry into the facility and met with Lelani Sams, to whom she explained the reason for the visit.

Community Care Licensing (CCL) has investigated the above listed allegations. The investigation consisted of a tour of the facility, interview of staff, and review of facility and outside source records.

It was reported to CCL that on 1/4/2023, during a visit to the facility, it was observed that client medications had been removed from the bubble packs, in which they were packaged by the pharmacy, prior to the time of administering, and the facility’s records reflected that staff signed off as if the medications had been administered. Interview with facility staff confirmed that staff pre-poured medications for clients by removing
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dawn Segura
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2023
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-20230105135624
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: R&A HOMES
FACILITY NUMBER: 374604188
VISIT DATE: 01/11/2023
NARRATIVE
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the medications from the original packaging, and staff initialed the facility’s medication administration record (MAR) at the time the medications were removed from the packaging, even though the medications were not administered to clients at the time.

Based upon the foregoing, the above listed allegations are substantiated. This finding means that the preponderance of the evidence standard has been met and the allegations are valid. Deficiencies are cited in accordance with California Code of Regulations, Title 22, Division 6, Chapter 8 and are noted on the attached LIC 9099-D.

An exit interview was conducted, and a copy of this report was provided to Lelani Sams at the conclusion of the visit. She 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: Lizzette Tellez
LICENSING EVALUATOR NAME: Dawn Segura
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 08-AS-20230105135624
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: R&A HOMES
FACILITY NUMBER: 374604188
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/31/2023
Section Cited
CCR
80075(k)(5)
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Each client's medication shall be stored in its originally received container. This requirement was not met, as evidenced by:

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Staff informed LPA that all staff have been made aware that medication shall not be removed from original packaging until the time of administering to each client and ensured to LPA that staff no longer pre-pour medications.
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Based upon interview, staff pre-poured medication and stored the medication in plastic cups until the times to administer to clients. This posed a potential health risk to 4 of 4 clients in care.
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Licensee agreed to provide staff training on medication administration and maintaining accurate records to all staff and submit proof of training by the POC due date of 1/31/2023
Type B
01/31/2023
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 was not met, as evidenced by:
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Staff informed LPA that the facility has implemented a new policy in which each client has a separate medication binder that houses the current MAR, and all staff have been made aware that medications are not to be popped out of bubble packs until the medications are actively administered to clients
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Based upon interview, licensee did not maintain a current medication administration Lrecord for clients. This posed a potential health risk for 4 of 4 clients in care.
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and the MAR is not to be initialed until medication has been administered.
Licensee agreed to provide staff training on medication administration and maintaining accurate records to all staff by POC due date of 1/31/2023
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: Dawn Segura
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3