392700123-11-5-2021-27-AS-LKIG-C8ZR3W-20211122114038

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700123
Report Date: 11/05/2021
Date Signed: 11/05/2021 02:46:43 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/27/2021 and conducted by Evaluator Bruce Jacobs

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20210927160134

FACILITY NAME:	BRIGHT FUTURES I		FACILITY NUMBER:	392700123
ADMINISTRATOR:	GINA HERNANDEZ		FACILITY TYPE:	735
ADDRESS:	2602 BREAKER WAY		TELEPHONE:	(209) 227-5983
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95209
CAPACITY:	5	CENSUS: 4	DATE:	11/05/2021
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Gina Hernandez, Facility Administrator		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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8
9

Facility did not dispense medication as prescribed

INVESTIGATION FINDINGS:

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13

Licensing Program Analyst (LPA) Bruce Jacobs arrived at the facility and met with Facility Administrator Gina Hernandez to deliver investigation findings on the above allegation. This investigation consisted of site inspections to the facility to conduct interviews with the facility administrator, staff and residents. LPA reviewed and obtained copies of the resident's files.

This investigation concluded that a resident (C-1) was not properly assisted with his medications. The resident had orders for three medications from 1/18/2019. Facility records did not document these medications being ordered, discontinued or administered as required.

As a result of this investigation, LPA finds the allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiency is cited on 9099-D, per Title 22 Regulations, Division 6.

Exit interview conducted and report provided. Appeals rights printed

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Bruce Jacobs
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021

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

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/27/2021 and conducted by Evaluator Bruce Jacobs

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20210927160134

FACILITY NAME:	BRIGHT FUTURES I		FACILITY NUMBER:	392700123
ADMINISTRATOR:	GINA HERNANDEZ		FACILITY TYPE:	735
ADDRESS:	2602 BREAKER WAY		TELEPHONE:	(209) 227-5983
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95209
CAPACITY:	5	CENSUS: 5	DATE:	11/05/2021
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Gina Hernandez, Facility Administrator		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not assist client with obtaining a medical appointment

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Bruce Jacobs arrived at the facility and met with Facility Administrator Gina Hernandez to deliver investigation findings on the above allegations. This investigation consisted of site inspections to the facility to conduct interviews with the facility administrator, staff and residents. LPA reviewed and obtained copies of the resident files.

This investigation concluded after several LPA inspections, interviews and record reviews that the facility had taken multiple steps and actions to assess and get treatment for a client's condition, beginning in December 2020. Multiple calls, video visits, office visits, specialist visits and hospital visits were arranged. Other sources provided information that was not consistent with the resident's record

Based on LPA’s observations and interviews conducted, the preponderance of evidence standard has not been met, therefore the above allegations are determined to be UNSUBSTANTIATED.

Exit interview conducted, Report provided.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Bruce Jacobs
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021

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

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 27-AS-20210927160134

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: BRIGHT FUTURES I	FACILITY NUMBER: 392700123
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/05/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/06/2021 Section Cited CCR 80075(b)(5)(B)	1 2 3 4 5 6 7	80075 Health Related Services (B) Once ordered by the physician the medication is given according to the physician's directions.	1 2 3 4 5 6 7	Plan of correction: The Facility Administrator will review the regulations of Incidental Medical and Dental Care and submit a statement of understanding and compliance. The facility will review medication administration procedures and ensure all staff are properly trained and management will provide oversight and regular medication audits.
	8 9 10 11 12 13 14	This requirement is not met by observation and records review. The resident had orders for three medications medications and it was documented that the medications were not administered to the resident and there was no records the medications were discontinued This poses a potential safety risk to client(s) 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.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Bruce Jacobs
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3