392700993-4-8-2022-27-AS-KHOS-CDGGYN-20220414054548

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700993
Report Date: 04/08/2022
Date Signed: 04/08/2022 12:07:33 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
02/22/2022 and conducted by Evaluator Michael Bilger

COMPLAINT CONTROL NUMBER: 27-AS-20220222105340

FACILITY NAME:	A1 DEL MONTE STOCKTON		FACILITY NUMBER:	392700993
ADMINISTRATOR:	SAINI, ANURADHA		FACILITY TYPE:	740
ADDRESS:	517 E. FULTON STREET		TELEPHONE:	(209) 910-5910
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95204
CAPACITY:	158	CENSUS:	DATE:	04/08/2022
		UNANNOUNCED	TIME BEGAN:	10:32 AM
MET WITH:	Jenna Silva		TIME COMPLETED:	12:05 PM

ALLEGATION(S):

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Medication- Facility not following Physicians order.

Medication- Facility staff failed to notify resident's Physician regarding medication.

INVESTIGATION FINDINGS:

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On 4-8-22 at 10:32am Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver complaint findings for the allegations noted above. LPA met with Jenna Silva and explained the purpose of the visit. Administrator Anuradha Saini was contacted and gave permission for Jenna to accommodate LPA and sign in her absence. Throughout this investigation LPA interviewed staff1 (S1), S2, S3, and S4. LPA also reviewed medication log sheets and orders for resident1 (R1) and reviewed facility progress notes along with Administrator’s certificate, medication bottle label, and LIC 308 form for Administrator designee.

Allegation: Facility not following Physician’s order: LPA reviewed physician orders for R1 which included a blood pressure medication to be given “two times per day.” Interviews conducted and medication log sheets reviewed revealed that R1 did not received this medication as ordered. Further review of blood pressure medication for R1 revealed no hold order from Physician. Based on interviews and record reviews, it was revealed that the blood pressure medication orders were not followed in that facility staff held R1’s medication without an order from R1’s physician to hold or stop giving the blood pressure medication to R1, and did not give the medication to R1 based on stated orders from Physician. As a result, the preponderance of evidence standard exists, therefore this allegation is SUBSTANTIATED.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022

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 27-AS-20220222105340

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: A1 DEL MONTE STOCKTON	FACILITY NUMBER: 392700993
	VISIT DATE: 04/08/2022

NARRATIVE

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Allegation: Facility staff failed to notify resident’s Physician regarding medication: Progress notes for R1 reviewed by LPA revealed three entries regarding a blood pressure medication order discrepancy. An entry on 2-3-22 states pharmacy was called. The following entry was on 2-15-22 which states clinic was called and staff was waiting for a response “within 24 hours.” The last entry was on 2-18-22 which states a staff member notified R1’s responsible person asking for assistance in obtaining a medication list. The progress notes did not specifically state a specific physician was notified to address the medication discrepancy for R1. The above information was also confirmed through staff interviews. Based on interviews and record reviews, it is determined that R1’s physician was not efficiently notified for medication order clarification for R1. As a result the preponderance of evidence standard exists, therefore this allegation is SUBSTANTIATED.

Deficiencies are cited under Title 22, Division 6. An exit interview was conducted with Jenna Silva and a copy of this report was left with Jenna. Appeal Rights provided.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 27-AS-20220222105340

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: A1 DEL MONTE STOCKTON	FACILITY NUMBER: 392700993
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/08/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/11/2022 Section Cited CCR 87465(e)	1 2 3 4 5 6 7	Incidental Medical and Dental Care. (e) For every prescription…medication for which the licensee provides assistance there shall be a signed, dated written order from a physician…This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee will ensure staff complete medication training on assisting residents with medication and following physician orders. Training date to be submitted to LPA by POC due date. Proof of training to be submitted to LPA by POC due date.
	8 9 10 11 12 13 14	Based on record reviews and interviews licensee did not ensure physician’s order for blood pressure medication was followed appropriately. Medication for R1 was held by facility staff and not given to R1 without a physician’s approved order to hold or stop medication. This poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
Type A 04/11/2022 Section Cited CCR 87465(a)(1)	1 2 3 4 5 6 7	Incidental Medical and Dental Care.A plan for incidental medical and dental care shall be developed by each facility (1)The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee will submit a plan which ensures physician’s are efficiently and effectively notified for any resident care needs. Plan to be submitted to LPA by POC due date.
	8 9 10 11 12 13 14	Based on record reviews and interviews, licensee did not ensure physician was efficiently notified for medication order clarification for R1. This poses an immediate health and safety 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.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022

LIC9099 (FAS) - (06/04)

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