374604544-9-13-2023-08-AS-DPOL-CW5T8F-20230929143017

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604544
Report Date: 09/13/2023
Date Signed: 09/13/2023 07:20:11 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
09/05/2023 and conducted by Evaluator Marisela Garcia-Centeno

COMPLAINT CONTROL NUMBER: 08-AS-20230905103636

FACILITY NAME:	PACIFICA SENIOR LIVING BONITA		FACILITY NUMBER:	374604544
ADMINISTRATOR:	MARKOVICH, PAUL		FACILITY TYPE:	740
ADDRESS:	3434 BONITA ROAD		TELEPHONE:	(619) 476-9444
CITY:	CHULA VISTA	STATE: CA	ZIP CODE:	91910
CAPACITY:	145	CENSUS: 110	DATE:	09/13/2023
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Executive Director, Emily DeLa Barre		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff did not administer medication as prescribed

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Marisela Garcia-Centeno made an unannounced visit to open an investigation and deliver findings on the above-mentioned allegation. LPA identified herself and disclosed the purpose of her visit. LPA met with Executive Director, Emily De La Barre and delivered the findings.

On September 5, 2023, Community Care Licensing (CCL) received a complaint alleging that staff did not administer medication as prescribed. It was specifically alleged that two medications were not administered as prescribed to one resident (R1) [an LIC 811 Confidential Names List was provided to staff to identify the resident]. The two medications in question were Alprazolam (Xanax) ordered on May 3, 2023, and Xidra Outer eye drops ordered on May 4, 2023. It was alleged that the Xanax was not administered on September 1 – 4, 2023, and that the Xidra eye drops were not administered for several days during the month of August 2023, (exact dates and times were not provided).

(continue at LIC 9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno	TELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023

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-20230905103636

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: PACIFICA SENIOR LIVING BONITA	FACILITY NUMBER: 374604544
	VISIT DATE: 09/13/2023

NARRATIVE

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(Continue from LIC9099)

On September 13, 2023, during a visit to the facility, a detailed review of R1’s medication administration records (MARs) disclosed that the Xanax medication for anxiety and sleep aid was to be administered 2x a day. This medication had a physician’s order stop date of 9/1/2023, and a new physician’s order was written on September 3, 2023, as a PRN (pro re nata) or as-needed basis. A detailed review of R1’s medication administration records indicated this medication was administered as prescribed. However, the Xidra eye drops were not administered as prescribed from August 7-15, 2023. A review of the MARs indicated the medication was “awaiting delivery”. There were no staff notes indicating that staff followed up with the pharmacy. Discussions with facility management indicated that the facility's standard protocols require medication technicians to follow up with the pharmacy as needed and to record follow-up attempts to ensure medications were administered as prescribed. Based on observations, staff interviews, and records review there was sufficient evidence to support the allegation that staff did not administer medications in accordance with doctor's orders.

The Department has investigated the above-mentioned allegation and has found that there was sufficient evidence to corroborate the allegation. Therefore, this allegation is substantiated. A substantiated finding means the allegation is valid because the preponderance of the evidence standard has been met. A deficiency was cited per Title 22, Division 6, Chapter 8 of the California Code of Regulations and is listed on LIC 9099-D. A plan of corrections was developed with Executive Director, Emily De La Barre.

An exit interview was conducted with Executive Director, Emily De La Barre and a copy of this report, Confidential Name List (LIC 811), along with Licensee/Appeal Rights (LIC 9058 03/22) were provided at the conclusion of the visit via email. Medication Technician, Alondra Martinez signed the report for Executive Director, DeLa Barre due to her absence. Report was emailed to Executive Director, Emily DeLaBarre with a confirmation receipt request at ed.bonita@pacificaseniorliving.com.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno	TELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20230905103636

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: PACIFICA SENIOR LIVING BONITA	FACILITY NUMBER: 374604544
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/13/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/13/2023 Section Cited CCR 87465(C)(2)	1 2 3 4 5 6 7	87465(C)(2) Incidental Medical and Dental Care. Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee agreed to conduct in service training on medication administration. Documentation of completion of training should be submitted to CCL by POC date of 10/13/2023
	8 9 10 11 12 13 14	Based on observations, interviews, and records review, facility staff did not administer medications in accordance with the physician’s orders for R1, which posed a potential health risk to 1 of 110 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: Denise Powell	TELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno	TELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023

LIC9099 (FAS) - (06/04)

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