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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392701156
Report Date: 03/23/2023
Date Signed: 03/23/2023 12:15:54 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
01/18/2023 and conducted by Evaluator Michael Bilger
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230118124439
FACILITY NAME:NANTUCKET RESIDENCE, THEFACILITY NUMBER:
392701156
ADMINISTRATOR:GESMUNDO, PAOLOFACILITY TYPE:
740
ADDRESS:3232 WISCONSIN AVETELEPHONE:
(209) 636-3456
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY:6CENSUS: 5DATE:
03/23/2023
UNANNOUNCEDTIME BEGAN:
09:59 AM
MET WITH:Orchid DamrichobTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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9
Staff do not distribute resident's medication as prescribed
Staff did not observe resident for change in condition
Licensee does not maintain a record for centrally stored medications
INVESTIGATION FINDINGS:
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On 3-23-23 at 9:59am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced at facility to deliver findings for the allegations noted above. LPA met with Administrator Orchid Damrichob and explained the purpose of the visit. During the course of this investigation, LPA reviewed facility file documentation including facility care notes for resident1 (R1), appraisal needs and service plan for R1, physician orders for R1, and medication log sheets for R1. LPA also conducted a facility observation on 1-19-23 and conducted interviews with Administrator and R1.
Allegation #1: Staff do not distribute resident’s medication as prescribed. LPA reviewed medication log sheets for October to December 2022, and January 2023. LPA also conducted a medication count with Administrator, and interviewed Administrator. Based on record reviews and interviews, it was determined that medication for R1, Losartan 50mg, was not indicated to be given as ordered on 11-30-22. Additionally, it was determined that medication for R1, Hydroxizine, was given from 12-1-22 to 12-16-22 after R1’s responsible person brought in medication and accepted by facility staff. {Cont. on 9099C}
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023
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 6
Control Number 27-AS-20230118124439
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: NANTUCKET RESIDENCE, THE
FACILITY NUMBER: 392701156
VISIT DATE: 03/23/2023
NARRATIVE
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It was further determined that R1 was receiving medication without a physician’s order on file at facility during the above noted time period. Additionally, based on medication count and review of medication logs, medication Trazodone had 19 pills present in a bottle which should have contained 22 pills, and medication Atrovastatin contained 21 pills in a bottle which should have contained 22 pills. Based on interviews and record reviews, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED.

Allegation #2: Staff did not observe resident for change in condition. LPA interviewed Administrator and reviewed care notes for R1. Based on interview and record reviews, it was determined that R1 was sent to the hospital on 1-4-23 due to a behavioral episode, and learned that R1 had contracted scabies. It was further determined that facility staff was aware of redness on R1, but not aware of scabies due to not providing evidence of an appropriate regulatory required observation of R1 including notifying family and Physician of R1. As a result, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED.

Allegation #3: Licensee does not maintain a record for centrally stored medication. LPA interviewed Administrator and reviewed medication log sheets for R1. This allegation refers to alleged inaccurate medication logs sheets regarding central stored medication for R1. Based on interview and record review, it was determined that medication log sheets for December 2022 were inaccurate in that medication Hydroxizine was noted on the log sheet for R1 and initialed by facility staff as given to R1, however, medication did not contain a written order from Physician and should not have been included on the log sheet as a result. Additionally, based on medication count and review of medication logs, medication Trazodone had 19 pills present in a bottle which should have contained 22 pills, and medication Atrovastatin contained 21 pills in a bottle which should have contained 22 pills, resulting in inaccuracies of R1’s medication records. As a result, the preponderance of evidence standard is met and this allegation is SUBSTANTIATED.

As a result of this allegation, citations are issued under Title 22, Division 6 and listed on LIC 9099D. An exit interview was conducted with Orchid Damrichob and a copy of this report was provided to Orchid. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 27-AS-20230118124439
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: NANTUCKET RESIDENCE, THE
FACILITY NUMBER: 392701156
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/24/2023
Section Cited
CCR
87465(a)(4)
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87465(a)(4) Incidental medical and dental care. (a) A plan for incidental medical and dental care shall be developed by each facility…(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by:
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Licensee will ensure completed staff training on assisting residents with medications and physician’s orders. Training date to be submitted to LPA by POC due date, with training to be completed no later than 2 weeks after the date of citation issuance. Proof of completed training to be submitted prior to citation clearance.
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Based on interview and record review, licensee did not ensure R1 received appropriate assistance with self-administered medications as per Physician’s orders. This posed an immediate health and safety risk to residents in care.
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Type A
03/24/2023
Section Cited
CCR
87466
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87466 Observation of the resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning…This requirement was not met as evidenced by:
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Licensee will submit a plan outlining facility’s procedures on proper on-going observation of residents in care. Plan to be submitted to LPA by POC due date.
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Based on interview and record review, licensee did not ensure proper observation of R1’s skin condition which included scabies. This posed an immediate health, safety, and resident rights risk to residents in care.
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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: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 27-AS-20230118124439
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: NANTUCKET RESIDENCE, THE
FACILITY NUMBER: 392701156
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/24/2023
Section Cited
CCR
87506(a)
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87506(a) Resident Records. (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident…This requirement was not met as evidenced by:
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Licensee will ensure completed training on maintaining appropriate medication records. Training date to be submitted to LPA by POC due date, with training to be completed no later than 2 weeks after the date of citation issuance. Proof of completed training to be submitted prior to citation clearance.
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Based on interview and record review, licensee did not ensure a complete and accurate record for R1 for multiple medications. This posed an immediate health and safety risk to residents in care.
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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: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
01/18/2023 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20230118124439

FACILITY NAME:NANTUCKET RESIDENCE, THEFACILITY NUMBER:
392701156
ADMINISTRATOR:GESMUNDO, PAOLOFACILITY TYPE:
740
ADDRESS:3232 WISCONSIN AVETELEPHONE:
(209) 636-3456
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY:6CENSUS: 5DATE:
03/23/2023
UNANNOUNCEDTIME BEGAN:
09:59 AM
MET WITH:Orchid DamrichobTIME COMPLETED:
11:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not assist resident with bathing
Staff do not resident with grooming
Staff are not safeguarding resident's personal property
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 3-23-23 at 9:59am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver findings for the allegations noted above. LPA met with Administrator Orchid Damrichob and explained the purpose of the visit. During this investigation, LPA interviewed Administrator and resident1 (R1), LPA also conducted a facility observation on 1-19-23. Additionally, LPA reviewed Physician’s report, care notes, and needs and service plan for R1 as well as inventory sheet for R1.
Allegation #1: Staff do not assist resident with bathing. LPA conducted interviews as noted above and conduct additional facility observation. Based on observation of facility and residents, LPA did not observe foul odors to indicate lack of bathing during observation. Based on interviews, it was determined that residents in care have been receiving bathing assistance from staff. LPA also observed used bathing assistant supplies available to staff for assisting residents As a result, there is not a preponderance of evidence to conclude resident is not receiving regular bathing assistance, and this allegation is UNSUBSTANTIATED.
{Cont. on 9099C}
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 27-AS-20230118124439
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: NANTUCKET RESIDENCE, THE
FACILITY NUMBER: 392701156
VISIT DATE: 03/23/2023
NARRATIVE
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Allegation #2: Staff do not assist resident with grooming. LPA conducted interviews as noted above and conduct additional facility observation. Based on observation of facility and residents, LPA observed residents to be appropriately clothed, with adequate grooming including combed hair, trimmed fingernails, and shaved hair as appropriate. No foul odors were observed by LPA. Additionally, LPA observed used grooming supplies available to staff for assisting residents as needed. Based on interviews, it was determined that residents in care have been receiving grooming assistance from staff. As a result, there is not a preponderance of evidence to conclude resident is not receiving regular bathing assistance, and this allegation is UNSUBSTANTIATED.

Allegation #3: Staff are not safeguarding resident’s personal belongings. Allegation referred to R1’s personal belongings as indicated by an allegation of R1 wearing another resident’s clothing item. Based on interview and record review, it was determined that R1 had worn a clothing item purchased by facility staff after R1’s admission. LPA observed item and receipt of purchase to concur item was purchased after admission. Based on review of R1’s inventory sheet, it was determined that R1’s items have been accounted for. As a result, there is not a preponderance of evidence to conclude facility did not ensure safeguarding of R1’s personal property during R1’s residency, therefore, this allegation is UNSUBSTANTIATED.

An exit interview was conducted with Orchid Damrichob and a copy of this report was provided to Orchid. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6