374604277-3-30-2022-08-AS-JRAE-CDX2RS-20220428173800

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604277
Report Date: 03/30/2022
Date Signed: 03/30/2022 03:46:25 PM

Unsubstantiated

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
11/23/2021 and conducted by Evaluator Kayla Hilario

PUBLIC

COMPLAINT CONTROL NUMBER: 08-AS-20211123090945

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:	03/30/2022
		UNANNOUNCED	TIME BEGAN:	03:20 PM
MET WITH:	Caregiver Molly Hernandez		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff provided unprescribed medication.

INVESTIGATION FINDINGS:

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Regional Manager (RM), Icela Estrada, and Licensing Program Analyst (LPA), Kayla Hilario, conducted an unannounced visit to deliver findings regarding the above-mentioned allegation. RM and LPA were allowed entry and met with Caregiver, Molly Hernandez. They identied themselves and discussed the purpose of the visit.

The Department’s investigation included a tour of the facility, observations, records reviews, and interviews with staff, residents, and outside sources. Prior to the investigation, LPA interviewed the reporting party and reviewed the facility file.

It was alleged that staff provided an unprescribed medication to a resident for pain. An audit of medications and review of the Medication Administration Record (MAR) revealed no inconsistencies and it was determined that medications are being administered as prescribed.
...Continued on 9099c.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: John Rante	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Kayla Hilario	TELEPHONE: (619) 481-0844
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022

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-20211123090945

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: SAFE HARBOR ELDER CARE	FACILITY NUMBER: 374604277
	VISIT DATE: 03/30/2022

NARRATIVE

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RM and LPA did not see or smell any unprescribed medications when conducting observations of both shared facility spaces and individual private bedrooms. For the purpose of interviews, resident records were reviewed, and residents were assessed for being qualified, alert, and oriented. When interviewing the alleged victim, it was conveyed that no alternative pain medications were administered. Other resident corroborated that they are able to advocate for their own pain management needs and have not been provided alternative pain medications or pain medications that are not prescribed to them. Interviews with staff determined that all but one resident is able to convey their need for a PRN for pain management and advocate for changes in their prescriptions. Further, an interview with staff revealed that no unprescribed medications are given to residents. Additionally, PRN and all medications are determined by a team of health professionals and delivered directly to the facility by the pharmacy; therefore, the Licensee nor staff are not involved in requesting changes in prescribed medication.

Based on observations, review of records, interviews, and outside sources, the investigation did not produce substantial evidence to meet the preponderance of evidence standard; therefore, the allegation is found UNSUBSTANTIATED.

An exit interview was conducted with Caregiver Molly Hernandez. A hard copy of this report and Licensee's Rights (LIC 9058 01/16) were provided to the Caregiver at the conclusion of the visit. .

SUPERVISOR'S NAME: John Rante	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Kayla Hilario	TELEPHONE: (619) 481-0844
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022

LIC9099 (FAS) - (06/04)

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