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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604734
Report Date: 10/17/2024
Date Signed: 10/17/2024 04:09:20 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
08/09/2024 and conducted by Evaluator Nacole Patterson
COMPLAINT CONTROL NUMBER: 08-AS-20240809083051
FACILITY NAME:CHANGING OPTIONSFACILITY NUMBER:
374604734
ADMINISTRATOR:MELCHER, JENNIFERFACILITY TYPE:
735
ADDRESS:500 3RD STREETTELEPHONE:
(714) 224-0826
CITY:RAMONASTATE: CAZIP CODE:
92065
CAPACITY:14CENSUS: 14DATE:
10/17/2024
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Program Manager Jennifer MelcherTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Licensee did not maintain accurate medication log.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegation. LPA introduced herself and disclosed the purpose of the visit to Program Manager Jennifer Melcher.

On 8/9/24 it was alleged that the Licensee did not maintain an accurate medication log. The Department’s investigation consisted of unannounced facility visits, review of facility and outside source records, interviews with facility staff, residents, outside sources, and LPA direct observations.

It was alleged that multiple client medication records were inaccurate, showing blank entries for medication administration passes. Nine (9) staff members aware of medication administration were interviewed during the investigation. Staff interviews confirmed that the Medication Administration Record (MAR) had missing entries. Staff explained that the blank entries were due to staff, at times, forgetting to document the medication pass in real time. (Continued on LIC9099-C p.2)
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Nacole Patterson
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 08-AS-20240809083051
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: CHANGING OPTIONS
FACILITY NUMBER: 374604734
VISIT DATE: 10/17/2024
NARRATIVE
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(Continued from LIC9099 p.1)

Additionally, staff informed that occasionally there were glitches in the computer system, resulting in documented passes being erased upon printing the document. Staff informed that while there were some missing entries, the medication passes were correctly administered to the clients.

Four (4) outside sources were interviewed during the investigation. Outside sources corroborated the allegation, informing that the records they received from the facility included missing administration entries, inconsistent administration times, and unknown amounts given for as needed (PRN) medications. Outside sources stated that administration discrepancies made it difficult for practitioners to accurately assess client progress and adjust medications safely.

During an unannounced facility visit, LPA directly observed the MAR with blank, unexplained entries from a previous day. LPA inquired with a staff member who informed that the medications were administered correctly, but the staff had forgotten to click the button to confirm the administration time. A sample of client MAR records from April 2024 showed nine (9) blank entries among three (3) clients, without notation or explanation regarding the medication passes.

Based on relevant interviews and records review, the preponderance of evidence has been met that the alleged violation occurred and is therefore substantiated. Deficiency is cited per California Code of Regulations, Title 22 (refer to the attached LIC9099-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Program Manager Jennifer Melcher, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Nacole Patterson
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 08-AS-20240809083051
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: CHANGING OPTIONS
FACILITY NUMBER: 374604734
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/18/2024
Section Cited
CCR
80070(a)
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The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client. This requirement was not met, as evidenced by:
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The Program Manager informed that weekly audit medication reviews went into effect on 9/11/24, and all medication staff were retrained via 6-hour medication training. An outside pharmacy conducted a 2-hour medication training on 10/1/24.
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Based on records, interviews, and observations, the Licensee did not ensure client medication administration records were accurate for 3 out of 14 clients (C3, C6, C8). This posed a potential health risk to clients in care.
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The training sign-in sheet and training completion certificates were submitted during the facility visit. The secondary check procedure will be submitted to LPA by the POC due date, as proof.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Nacole Patterson
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
08/09/2024 and conducted by Evaluator Nacole Patterson
COMPLAINT CONTROL NUMBER: 08-AS-20240809083051

FACILITY NAME:CHANGING OPTIONSFACILITY NUMBER:
374604734
ADMINISTRATOR:MELCHER, JENNIFERFACILITY TYPE:
735
ADDRESS:500 3RD STREETTELEPHONE:
(714) 224-0826
CITY:RAMONASTATE: CAZIP CODE:
92065
CAPACITY:14CENSUS: 14DATE:
10/17/2024
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Program Manager Jennifer MelcherTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff did not administer residents' medication as prescribed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced herself and disclosed the purpose of the visit to Program Manager Jennifer Melcher.

On 8/9/24 it was alleged that staff did not administer residents’ medication as prescribed. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review.

Eleven (11) staff members who worked for the facility during the timeframe of complaint were interviewed. Staff interviews did not corroborate the allegation, staff members informed that there had been no medication errors during the timeframe of complaint. Staff interviews also revealed that the two clients named in the complaint did not live at the licensed facility in question, but at separate facilities outside of the Department’s jurisdiction. (Continued on LIC9099-C p.2)
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Nacole Patterson
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 08-AS-20240809083051
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: CHANGING OPTIONS
FACILITY NUMBER: 374604734
VISIT DATE: 10/17/2024
NARRATIVE
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(Continued from LIC9099 p.1)

Facility rosters corroborated staff statements, showing that the clients in question did not live at this licensed location. No records were found to show that medication errors had occurred with clients who lived at the licensed facility in question. The Department initiated for an investigation to occur at the facility where the medication error happened.

Nine (9) clients who received medication during the timeframe of complaint were interviewed. Client interviews did not corroborate the allegation, as seven (7) clients informed their medications were administered on time and correctly. Two (2) clients did not provide answers regarding medications when questioned during interviews. An additional client was attempted for interview during two unannounced visits, but declined interview for both requests.

Four (4) outside sources were interviewed during the investigation. Outside sources did not know of a medication error that had occurred with a client at the facility. While outside sources interviewed expressed concerns with the accuracy of the Medication Administration Record (MAR) and the potential for medication errors as a result, they did not have knowledge or evidence of an actual administration error that had occurred.

Based on interviews and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Program Manager Jennifer Melcher, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Nacole Patterson
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5