<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700173
Report Date: 10/14/2021
Date Signed: 10/14/2021 12:34:38 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
10/12/2021 and conducted by Evaluator Ashley Boothe
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20211012114102
FACILITY NAME:PEOPLE'S CARE WILLORAFACILITY NUMBER:
392700173
ADMINISTRATOR:SIMON, ARNEATHAFACILITY TYPE:
735
ADDRESS:949 WILLORA RDTELEPHONE:
(209) 957-3662
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY:5CENSUS: 4DATE:
10/14/2021
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Arneatha SimonTIME COMPLETED:
12:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not administer medications as prescribed
Staff falsified client's records
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 10/14/2021 at 9:40am, Licensing Program Analyst (LPA) Ashley Boothe arrived unannounced to open a 10 day complaint investigation with the following allegations: staff did not administer medications as prescribed and staff falsified clients records. LPA met with Administrator and explained the purpose of today’s visit. LPA was allowed entry into the facility, current census is 4.

During the course of the investigation LPA conducted on site inspection, reviewed records, and conducted interviews.

LPA reviewed incident reported of Resident one (R1) missing medication administration of pm medications reported to Administrator. Administrator conducted internal investigation. Interviews and records reviewed concluded medications narcotic count for R1 medications were altered to reflect missed pm medications administration per physicans' order. R1's physician was notified of missed administration.

Continued on 9909 C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Ashley Boothe
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
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
Control Number 27-AS-20211012114102
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: PEOPLE'S CARE WILLORA
FACILITY NUMBER: 392700173
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/15/2021
Section Cited
CCR
80075(b)
1
2
3
4
5
6
7
Health Related Services (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidence by:
1
2
3
4
5
6
7
The licensee agrees to submit proof of scheduled staff training from Registered Nurse Consultant for medications administration to LPA by POC due date and proof of in service upon completion of training.
8
9
10
11
12
13
14
Based on observation, interview and record review the licensee did not comply with the section cited above in that R1 missed administration of pm medications which poses an immediate health, safety, and personal rights risk to residents in care.
8
9
10
11
12
13
14
Type B
10/22/2021
Section Cited
CCR
80065(a)
1
2
3
4
5
6
7
Personnel Requirements(a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.

This requirement is not met as evidence by:
1
2
3
4
5
6
7
The licensee agrees to submit proof of training to include medications administration, reporting requirements, standards for record keeping, personal rights, and ethics to LPA by POC due date.
8
9
10
11
12
13
14
Based on observation, interview and record review the licensee did not comply with the section cited about in that S1 was not competent in medications record keeping and falsified records for R1's missed medication administrations on narcotics count and MAR which poses a potential health, safety, and personal rights risk to residents in care.
8
9
10
11
12
13
14
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: Ashley Boothe
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20211012114102
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: PEOPLE'S CARE WILLORA
FACILITY NUMBER: 392700173
VISIT DATE: 10/14/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Based on information obtained the aforementioned allegations are SUBSTANTIATED. A finding that the complaint is substantiated means the preponderance of evidence standard has been met, therefore the allegation(s) is found to be substantiated.

Per California Code of Regulations (CCRs) - Title 22, Division 6, the following deficiencies are being cited on the attached 9099D during this visit. The Administrator was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. Exit interview and a copy of report was given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Ashley Boothe
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3