374604441-9-8-2023-08-AS-DNGN-CVGUTR-20230908155222

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604441
Report Date: 09/08/2023
Date Signed: 09/08/2023 03:53:26 PM

Document Has Been Signed on 09/08/2023 03:53 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	MONTE VISTA VILLAGE SENIOR LIVING		FACILITY NUMBER:	374604441
ADMINISTRATOR:	MARKOVICH, PAUL		FACILITY TYPE:	740
ADDRESS:	2211 MASSACHUSETTS AVENUE		TELEPHONE:	(619) 465-1331
CITY:	LEMON GROVE	STATE: CA	ZIP CODE:	91945
CAPACITY:	219	CENSUS: 124	DATE:	09/08/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Executive Director Adrian Gullien and Resident Services Director Monica Maldonado		TIME COMPLETED:	04:10 PM

NARRATIVE

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LPA Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management – Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Adrian Gullien and Resident Services Director Monica Maldonado.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 08/18/2023). According to the LIC624: during the morning of 08/17/2023, an error by Staff #1 (S1) led to Resident #1 (R1) receiving doses of multiple medications which were not prescribed to them. These medications were instead prescribed to Resident #2 (R2). [See LIC 811 Confidential Names List for a description of select person identifiers used in this report].

During today’s visit, LPA performed a brief facility tour, reviewed pertinent care records, and interviewed relevant staff.

Records and staff interviews showed: R1 relied on License’s staff for help with storing and taking their prescribed medications. Licensee taught its medication technicians to use plastic holding/transport containers during medication pass. These containers were subdivided, with each partition being labeled with the resident’s full name, room number, and profile photograph. During the incident, S1 chose to not use this labeled container(s), which contributed to them mistakenly giving R2’s medicines to R1.

[CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023

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

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: MONTE VISTA VILLAGE SENIOR LIVING	FACILITY NUMBER: 374604441
	VISIT DATE: 09/08/2023

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[CONTINUED FROM LIC 809]

Licensee’s staff timely notified R1’s primary care physician (PCP), hospice agency, and responsible person. Licensee adhered to PCP instructions, which included measuring R1’s blood sugar and blood pressure over the next twelve (12) hours. R1’s initial “sleepiness” subsided after a few hours; they did not suffer any other negative health consequence from the incident. The medication errors which affected R1 on morning of 08/17/2023 did not prevent R2 from receiving their respective prescribed medications on that date. Licensee immediately removed S1 from medication pass duties and had them undergo retraining (to include skills validation).

A preponderance of evidence exists to show: During the incident in question, License’s staff (S1) did not give R1 medications as they were prescribed. The incident did not result in injury or serious illness to R1. One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the Licensee. LPA also issued two (2) Technical Violations (TV) regarding reporting requirements.

An exit interview was conducted with Gullien, to whom a copy of this report, the LIC 809-D, the LIC9102-TV pages, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/08/2023 03:53 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: MONTE VISTA VILLAGE SENIOR LIVING	FACILITY NUMBER: 374604441
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/08/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/08/2023 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care: “(a)(4) The licensee shall assist residents with self-administered medications as needed.” This requirement was not met, as evidenced by:	1 2 3 4 5 6 7	Per Licensee, S1 resigned from employment in early September 2023. Licensee agreed to retrain its remaining medication technicians and nurses on accurate medication pass procedures, to include required use of the labeled holding/transport containers and “The Seven Rights of Medication Administration.” Licensee agreed to E-mail LPA a copy of the training sign in sheet, by the POC due date.
	8 9 10 11 12 13 14	Based on records and interviews, the licensee did not assist 1 of 124 residents (R1) with self-administered medications as needed/prescribed, which posed a potential health risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023

LIC809 (FAS) - (06/04)

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