392701033-8-27-2023-27-AS-KHOS-CVTSLP-20230919135840

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392701033
Report Date: 08/25/2023
Date Signed: 08/27/2023 08:43:59 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
07/17/2023 and conducted by Evaluator Albert Johnson

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20230717083405

FACILITY NAME:	ST. RITA CARE HOME		FACILITY NUMBER:	392701033
ADMINISTRATOR:	TALONGWA, CATHERINE		FACILITY TYPE:	740
ADDRESS:	3478 LADD TRACT CT.		TELEPHONE:	(650) 465-2526
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95206
CAPACITY:	6	CENSUS: 4	DATE:	08/25/2023
		UNANNOUNCED	TIME BEGAN:	10:37 AM
MET WITH:	Maggie Kiago		TIME COMPLETED:	12:08 PM

ALLEGATION(S):

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Staff did not dispense medication as prescribed.
Resident not accorded dignity in relationships with staff.

INVESTIGATION FINDINGS:

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LPA Johnson arrived at the care facility and met with Staff to deliver findings for the above allegations.

Allegation: Staff did not dispense medication as prescribed.
Based on review of the records the facility did not have medications for R1. Review of R1's medication by LPA Johnson confirmed missing medication. It was discovered that R1 orders her own medications and needs reminders from the staff to order these medications. R1's physician's report does not support R1's total ability to self administer prescription medications and needs assistance from the facility to manage these medications including reordering. R1 missed five days of two medications; these medications include a diuretics and a beta-blocker (hypertension).

Substantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023

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

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20230717083405

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: ST. RITA CARE HOME	FACILITY NUMBER: 392701033
	VISIT DATE: 08/25/2023

NARRATIVE

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Allegation: Resident not accorded dignity in relationships with staff.
During the course of the investigation the facility did not encourage R1 to use her head phones or have a place for R1 to conduct business without having the other residents, staff or visitors from hearing the conversations and sometimes having others engaging in the conversations that R1 was having with family or about medications.

R1 also has very personal documents with banking, medical, business information out and easily accessible for others to view.

The preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. California Code of regulations, Title 22. Deficiencies are being cited on the attached LIC9099D.

Exit interview conducted

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 27-AS-20230717083405

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: ST. RITA CARE HOME	FACILITY NUMBER: 392701033
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/25/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/26/2023 Section Cited CCR 87465(c)(2)	1 2 3 4 5 6 7	Incidental Medical and Dental Care Once ordered by the physician the medication is given according to the physician's directions. This requirement has not been met as evidenced by:	1 2 3 4 5 6 7	Facility Administrator will perform an audit of the medications to ensure accuracy of counts and administration.
	8 9 10 11 12 13 14	The Licensee failed to ensure R1 had medications as prescribed. LPA observed R1 missed five days of two medications. This violation poses an immediate health and safety risk to the residents in care.	8 9 10 11 12 13 14	Facility will perform comprehensive retraining of all med staff and sent CCL proof of retraining by the POC due date.
Type B 09/08/2023 Section Cited CCR 87468.1(a)(3)	1 2 3 4 5 6 7	(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(3)To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.	1 2 3 4 5 6 7	The facility will work with R1 and locate an area that will allow for privacy to allow R1 to conduct business without interruption.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by interviews and records reviewed confirmed that R1 does not have a place to conduct business without having the other residents, staff or visitors from hearing the conversations and sometimes having others engaging in the conversations that R1 was having with family or about medications., this posed a personal rights violation to resident.	8 9 10 11 12 13 14	The plan will be submiited to the department via email by 9/8/2023.

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: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023

LIC9099 (FAS) - (06/04)

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