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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 380540203
Report Date: 04/28/2022
Date Signed: 04/28/2022 12:36:13 PM

Substantiated


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 HOUSEFACILITY NUMBER:
380540203
ADMINISTRATOR:ANGELINA GUZMANFACILITY TYPE:
740
ADDRESS:399 BUENA VISTA EASTTELEPHONE:
(415) 863-1721
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94117
CAPACITY:87CENSUS: 44DATE:
04/28/2022
UNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Administrators, Hazel Castro and Angelina GuzmanTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Medication logs are not adequately documented.
INVESTIGATION FINDINGS:
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On 4/28/2022, 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, and Hazel Castro and explained the purpose of the visit.

Regarding medication logs are not adequately documented, according to the Medication Technicians (Med Techs), they prepare the medication in a plastic bag with resident's information on it for the caregivers to give it to the residents. After the medications are given, the caregivers return the plastic bags and the Med Techs retrieve the plastic bags, and document it in the resident's Electronic Medication Administration Record accordingly.

In regards to documentation of the PRN (as needed) medication, when a resident requests for their PRN medication, if Med Techs are at the facility, they will prepare it, give it to resident and document it in the resident's Electronic Medication Record. However, if they are not at the facility, the assigned caregiver will get it from the medication cabinet that is located at the receptionist desk, logs it on the PRN medication log, signs it and gives it to the resident.

Based on the documentation provided, LPA observed the PRN Medication logs and the Electronic Medication Administration Records indicated numerous PRN entries that had not been entered and initialed by the staff who gave the medication.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
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 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: 04/28/2022
NARRATIVE
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Based on interviews and record review during the investigation, the preponderance of evidence standard has been met. Therefore, this allegations were determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties.

Report was discussed with Administrators, and Appeal Rights provided.

A copy is provided.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/12/2022
Section Cited
CCR
87506(a)
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Resident Records..(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility....This requirement was not met as evidenced by:
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The administrator and/or the designee will provide in-service to staff who gave medication to residents regarding proper documentation and provide a copy of the lesson plan and a copy of the sign-in sheet
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Based on the documentation provided by the facility, it indicated that numerous PRN and routine medications were not initialed and entered by staff who gave the medication which posed potential health and safety risks to resident in care.
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to CCL by the plan of correction due date 5/12/2022.
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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.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3