374604277-7-26-2021-08-AS-DPOL-C5F2WG-20210730174530

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604277
Report Date: 06/09/2021
Date Signed: 07/26/2021 02:21:50 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
09/02/2020 and conducted by Evaluator Evangelica Torres

COMPLAINT CONTROL NUMBER: 08-AS-20200902162910

FACILITY NAME:	SAFE HARBOR ELDER CARE		FACILITY NUMBER:	374604277
ADMINISTRATOR:	RATHI, GAURAV		FACILITY TYPE:	740
ADDRESS:	3301 LOMAS SERENAS DRIVE		TELEPHONE:	(619) 791-5495
CITY:	ESCONDIDO	STATE: CA	ZIP CODE:	92029
CAPACITY:	6	CENSUS: 6	DATE:	06/09/2021
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Administrator, Gaurav Rathi		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Staff administered resident medication without a physician's order

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Eva Torres conducted a visit to deliver findings on the above allegation. LPA identified herself, spoke with Mr. Rathi, and disclosed the purpose of the visit. The investigation included multiple interviews and a review of records.

It was alleged that the licensee administered a discontinued medication to Resident's #1 (R1) (See LIC 811- Confidential Names List) from June 2020 through September 2020.

On or about June 2020 and August 2020, the licensee administered a medication (M1) to R1 without a prescription. On September 01, 2020, the licensee again administered M1 to R1 without a physician's order.
LPA reviewed R1's records including, but not limited to the Physician's Report dated March 02, 2020, Pre-admission assessment dated May 12, 2020, Medication Records System Logs from June 2020 through September 2020, medication's orders from March 2020 through September 2020, and the home health records from March 2020 through May 2020.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Hedgecock	TELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Evangelica Torres	TELEPHONE: (619) 900-1407
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20200902162910

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: SAFE HARBOR ELDER CARE	FACILITY NUMBER: 374604277
	VISIT DATE: 06/09/2021

NARRATIVE

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According to the review of the documents, R1 was admitted at the facility on June 01, 2020, with home health services. R1’s records revealed that they required assistances with bathing, grooming, dressing, emotional support, and medication management. The records further showed that R1's treating physician is also the physician with the home health agency. In reviewing the home health records, it confirmed that R1 received nursing services from March 22, 2020, through May 12, 2020. On May 12, 2020, R1 was discharged from home health, as R1 met their care goals. However, R1 remained with their treating physician.

LPA also reviewed R1's medication list and the facility's medication record logs from June 2020 through September 2020 and the records showed that the licensee had not administered M1 to R1 until September 01, 2020. An interview with the home health agency confirmed that the licensee was given R1's medication list, at which M1 was listed on the sheet as a PRN medication, which means as needed. The interview also revealed that R1’s treating physician had not discontinued the medication in question, and no changes were made to M1 until September 10, 2020.

Though staff interviews did not support the allegation, an email received by the licensee on September 04, 2020, confirmed that the licensee did administered M1 to R1 on September 01, 2020, as prescribed. Due to R1's cognitive impairment, LPA was unable to obtain an interview. LPA also interviewed additional outside sources. However, their interviews were found to be inconsistent to support the allegation.

Based on interviews conducted and a review of documents, there is insufficient evidence to prove or disprove that the allegation occurred; therefore, the complaint investigation findings are found to be unsubstantiated. LPA conducted an exit interview with Administrator, Gaurav Rathi. The Licensee's Rights (LIC9058 01/16) and a copy of this report with their signature were provided to Mr. Rathi. A return email or reply receipt from the administrator will confirm receipt of documents. This is an amended version of the original report created on 06/09/21.

SUPERVISOR'S NAME: Rebecca Hedgecock	TELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Evangelica Torres	TELEPHONE: (619) 900-1407
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2021

LIC9099 (FAS) - (06/04)

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