392700298-8-30-2023-27-AS-LKIG-CV8TN9-20230831145222

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700298
Report Date: 08/29/2023
Date Signed: 08/30/2023 02:39:58 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, 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
06/30/2023 and conducted by Evaluator Arielle Pascua

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20230630113649

FACILITY NAME:	DIZON VALLEY CARE HOME		FACILITY NUMBER:	392700298
ADMINISTRATOR:	DIZON, LISSET		FACILITY TYPE:	735
ADDRESS:	2830 SAN ROCCO DR		TELEPHONE:	(510) 435-7428
CITY:	TRACY	STATE: CA	ZIP CODE:	95376
CAPACITY:	6	CENSUS: 5	DATE:	08/29/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Mary Baldwin		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not give residents their medications on a timely basis.

INVESTIGATION FINDINGS:

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

On 08/29/2023, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to conduct a complaint visit. LPA was greeted by Facility Designated Representative (FDR), Mary Baldwin and explained the purpose of the visit. The purpose of the visit was to deliver complaint findings.

Current census is 5. 4 out 5 residents were out at their respective day program. 1 out 5 residents were out at their job at this time.

Allegation: Staff did not give residents their medications on a timely basis.
It was alleged that staff did not give residents their medications on a timely basis. During the course of this investigation LPA conducted interviews and reviewed staff files. Based on interviews conducted it was learned that on 06/14/2023 R1 and R2's service coordinator visited the facility around 6:45pm to obtain signatures. It was observed during the visit that R1 an R2 were in their bedrooms.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

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 2

Control Number 27-AS-20230630113649

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: DIZON VALLEY CARE HOME	FACILITY NUMBER: 392700298
	VISIT DATE: 08/29/2023

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

The following day R1's and R2's Service Coordinator came back and observed that the resident's were not in the bedrooms. It was learned that on 06/14/2023, R1 and R2 have been up since 4:00am because they had to leave to day program early in the morning. R1 and R2 did not come back to the facility until around 4:30pm and had dinner at 5:00pm. It was learned that R1 and R2 asked to go into their rooms to relax after dinner because they had a long day at program. An interview with staff was conducted and it was denied that medication was given early. It was stated that staff best practice for staff to administer medication was during 8:00am for AM meds, 12:00pm for noon meds, and 8:00pm for PM meds. Staff state that they try to provide medication as close to scheduled time as possible. An interview with 4 residents were conducted. 4 out 4 residents deny that they get their medications early. 4 out 4 residents do not have any issues with receiving their medication.
A review of the Medication Administration Record was conducted. LPA did not observe any indications or errors during the time of June 2023.

As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred.

There were no deficiencies observed or cited at this time. An exit interview was conducted, a copy of the 9099 and 9099-C was provided to the facility.

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2