374604348-12-20-2023-08-AS-IESA-CYYPV2-20231229103826

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604348
Report Date: 12/20/2023
Date Signed: 12/20/2023 04:47:14 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
08/05/2021 and conducted by Evaluator Marisela Garcia-Centeno

COMPLAINT CONTROL NUMBER: 08-AS-20210805151845

FACILITY NAME:	UTAH FACILITY CARE		FACILITY NUMBER:	374604348
ADMINISTRATOR:	ROKSANDIC, RADA		FACILITY TYPE:	735
ADDRESS:	662 UTAH WAY		TELEPHONE:	(442) 777-2024
CITY:	ESCONDIDO	STATE: CA	ZIP CODE:	92025
CAPACITY:	6	CENSUS: 5	DATE:	12/20/2023
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Administrator, Dragan Roksandic		TIME COMPLETED:	02:25 PM

ALLEGATION(S):

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Staff did not administer medication as prescribed
Staff did not provide individual privacy to client
Staff did not treat client with dignity and respect

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced complaint visit to deliver investigative findings. LPA was greeted by Caregiver, Virgilio Prado. LPA delivered findings via telephone with Administrator, Dragan Roksandic.

The Department investigated the above-listed complaint allegations. The investigation consisted of observations, interviews with facility staff, clients, and outside sources, and a review of relevant records.

On August 5, 2021, Community Care Licensing (CCL) received a complaint alleging that facility staff did not administer medication as prescribed. Specifically, it was alleged that Client (C1) [staff were provided an LIC811 Confidential Names to identify C1] did not receive their medications for five (5) days after they were placed at the facility. A review of C1’s admissions agreement indicated that C1 was a newly admitted client on July 27, 2021. (Continue at LIC9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023

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-20210805151845

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: UTAH FACILITY CARE	FACILITY NUMBER: 374604348
	VISIT DATE: 12/20/2023

NARRATIVE

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(Continue from LIC9099

Review of the facility and C1’s records as well as available correspondence, determined the placement agency did not arrange for the medications to be ready at the time of placement. When C1 was transferred to the facility they did not bring all of their medications. During staff interviews, it was indicated that despite their efforts to transfer the medications from the pharmacy to the facility, there was a delay due to problems with insurance coverage. In addition, neither the facility nor the pharmacy had current physician’s orders, which resulted in a delay in processing the prescription. Once C1’s attending physician placed new medication orders, C1’s medical insurance approved the prescription. On August 2, 2021, C1’s medications were delivered to the facility and staff were able to administer them as ordered. A review of CCL incident reports submitted by the facility regarding this incident indicated no violations of Title 22 regulations in the handling of this situation. In addition, Title 22 reporting requirements were met. A review of the incident reports submitted indicated no adverse reactions for not taking the medication as C1 did not express any agitation, anxiety, or aggression toward staff or clients during the period of this incident. Based on records review and staff interviews, once the staff had the current physician’s orders, medication was administered to C1 as prescribed.

It was also alleged that staff did not provide individual privacy to C1. It was specifically alleged that staff entered the bathroom while C1 was using it. Details of when this incident occurred, or which staff member was involved were not identified during the investigation. Multiple interviews with staff and clients did not disclose any evidence of staff entering the bathroom while any clients were using it. During a visit to the facility conducted on August 13, 2021, observations showed the doors to both of the bathrooms had locking mechanisms from the inside of the bathrooms.

Lastly, it was also alleged that facility staff did not treat C1 with dignity and respect. It was specifically alleged that staff did not allow C1 access to the facility telephone. An interview conducted on August 13, 2021, with C1, confirmed they were allowed access to the house telephone and did not support the allegation. C1 stated that the facility staff were nice and treated them with respect. Multiple interviews with staff and clients consistently indicated that clients had access to the house phone as needed.

(Continue at LIC9099C)

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 08-AS-20210805151845

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: UTAH FACILITY CARE	FACILITY NUMBER: 374604348
	VISIT DATE: 12/20/2023

NARRATIVE

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(Continue from LIC9099C)

Based on record reviews and interviews with staff, clients, and outside sources, there was insufficient evidence to support the allegations in this report. The Department has investigated the above-mentioned allegations and based on interviews and records review, the preponderance of the evidence has not been met, therefore, these allegations are deemed unsubstantiated.

An exit interview via telephone was conducted with Administrator, Dragan Roksandic. A copy a copy of this report, LIC 811 Confidential Names, and the Licensee Appeal Rights (LIC9058 01/16) was provided to Caregiver, Virgilio Prado at the conclusion of the visit.

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023

LIC9099 (FAS) - (06/04)

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