380540203-4-28-2022-14-AS-JMOS-CDXVA6-20220429161521

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 380540203
Report Date: 03/29/2022
Date Signed: 04/28/2022 12:24:07 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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/12/2022 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20220112101835

FACILITY NAME:	BUENA VISTA MANOR HOUSE		FACILITY NUMBER:	380540203
ADMINISTRATOR:	ANGELINA GUZMAN		FACILITY TYPE:	740
ADDRESS:	399 BUENA VISTA EAST		TELEPHONE:	(415) 863-1721
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94117
CAPACITY:	87	CENSUS: 45	DATE:	03/29/2022
		UNANNOUNCED	TIME BEGAN:	12:01 PM
MET WITH:	Co-Administrator, David Wall, Administrators, Hazel Castro and Angelina Guzman		TIME COMPLETED:	12:50 PM

ALLEGATION(S):

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Staff are not adequately trained.
Medications are not being administered to residents according to physician's instructions.

INVESTIGATION FINDINGS:

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4/28/22- This report has been amended on this date after superviosor's review.

On 3/29/2022, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20220112101835. LPA Han was properly screen at the front entrance. LPA Han met with administrators, Angelina Guzman, Hazel Castro, Co-administrator, David Wall and explained the purpose of the visit.

Regarding to allegation of- staff are not adequately trained, LPA Han interviewed the administrator who denied the allegation and stated that the facility provided in-services to staff on assisting residents with their medications. After the in-services, each staff was given an exam and if they passed the exam, they were presented with a certificate of completion and if they failed, they have to retake the exam. LPA interviewed 8 facility staff on different shifts and all of them validated that they were trained, they passed the exam and they were presented with a certificate of completion. LPA also reveiwed the staff training sign-in records from February, 2021 and a copy of the certificates that were issued to the staff upon their completion of the training.

Base on record review and interviews during the course of investigation, this allegation is unsubstantiated.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022

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 14-AS-20220112101835

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: BUENA VISTA MANOR HOUSE	FACILITY NUMBER: 380540203
	VISIT DATE: 03/29/2022

NARRATIVE

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Regarding allegation of- Medications are not being administered to residents according to physician's instructions. There is no additional information forthcoming from the Reporting Party and the investigation was based on the information that was provided during the initial reporting that the Reporting Party alleged the facility prepared medications more than 24 hours ahead, the person who gives the medication does not know the medication orders, there was no follow-up when residents refused their medications, staff were not aware of the PRN (as needed) medication orders and facility does not keep up with updating the new medication order.

During the investigation, LPA interviewed two Medication Technicians (Med Techs) and caregivers regarding to the above allegation. The Med Techs denied that the medications were prepared 24 hours ahead. LPA toured the medication storage cabinet and did not observe any medications were prepared 24 hours in advance. The Med Techs also reported that prior to preparing the medications, they always reviewed the physician's orders, then they would prepare the medication for the facility staff who would give it to the residents whom they are assigned to. Furthermore, to ensure the accuracy of the medication orders, the facility conducts a monthly medication reconciliation with the pharmacy, or the attending physician to review the resident's routine and PRN (as needed) medication orders. LPA reviewed the medication reconciliation records for December 2021 and it revealed that the process was completed by one of the Med Techs.

Concerning to the facility does not follow-up if there is a refusal of medications, the Med Techs stated that there are very few incidences where the residents refused their medication(s) but if that happens, the facility staff would report it to one of them right away and they would follow-up with the resident and the physician accordingly. However, if they are not at the facility, the staff would contact them by phone and/or write an endorsement note for them to follow-up. LPA interviewed 8 facility staff and all of them validated this process.

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 14-AS-20220112101835

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: BUENA VISTA MANOR HOUSE	FACILITY NUMBER: 380540203
	VISIT DATE: 03/29/2022

NARRATIVE

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Concerning to PRN medication orders that staff is not aware of, the Medication Technicians stated that when there is a change to the existing PRN medication order or a new PRN medication order from the attending physician, one of them would be notified and they would verify the order, input the order into the resident's electronic Medication Administration Records and follow-up with the new medication order accordingly.

Furthermore, LPA interviewed 4 residents regarding to their experience with staff assisting them with their medication and all of them reported that they did not have any problems with receiving their medications from the facility staff and they have not experienced getting the wrong medication from the facility staff.

Base on record review, observation, and interviews during the course of investigation, this allegation is unsubstantiated.

Although the above investigations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

This report is reviewed and discussed with administrators. A copy is provided.

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022

LIC9099 (FAS) - (06/04)

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