397000250-10-20-2023-27-AS-KHOS-CX5PTW-20231031113636

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 397000250
Report Date: 10/20/2023
Date Signed: 10/20/2023 01:19:26 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
10/04/2023 and conducted by Evaluator Michael Bilger

COMPLAINT CONTROL NUMBER: 27-AS-20231004110324

FACILITY NAME:	MELMAR'S GUEST HOME #2		FACILITY NUMBER:	397000250
ADMINISTRATOR:	CAMERO, MARICOR		FACILITY TYPE:	735
ADDRESS:	6801 MONTAUBAN AVENUE		TELEPHONE:	(209) 683-6876
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95210
CAPACITY:	6	CENSUS: 4	DATE:	10/20/2023
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Maricor Junson		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Staff did not properly administer medications to resident while in care

INVESTIGATION FINDINGS:

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On 10-20-23 at 11:15am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver findings for the allegation noted above. LPA met with Administrator Maricor Junson and explained the purpose of the visit. During this investigation, LPA conducted interviews with five staff members. LPA also reviewed medication log sheets for resident1 (R1) for June-September 2023, physician’s report for R1, photo submitted by facility, and individualized program plan (IPP) for R1.
Based on interviews and record reviews, it was determined that during R1’s residency until 9-24-23, R1 received medication from various staff members. Interviews further revealed that various facility staff handed multiple medication for R1, however, did not fully supervise to ensure R1 took this medication as R1 would take medication in hand and walk away from staff. It was further reported through interviews that during R1’s residency, R1 engaged in increasingly aggressive behavior including combativeness and verbal confrontations with staff. Interviews with staff and record reviews further revealed that at least three medications prescribed to R1 were to assist with mood stabilization. {Cont. on 9099C}

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

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-20231004110324

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: MELMAR'S GUEST HOME #2	FACILITY NUMBER: 397000250
	VISIT DATE: 10/20/2023

NARRATIVE

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R1’s IPP reviewed and dated 7-31-23 states that facility will “ensure R1 takes medications as prescribed by the physician.” R1’s physician’s report revealed R1 is unable to administer and store own medication. A photograph submitted by facility staff illustrated multiple medications inside and outside original packaging. Based on interviews and record reviews, on 9-24-23, after R1 moved out of the facility, staff discovered multiple medications previously given to R1 by staff stored in R1’s pocket of his jacket and other areas of R1’s room. Interviews confirmed that these medications belonged to R1.

It was determined through this investigation that facility staff did not take steps to appropriately ensure that R1 consumed various medications as required by R1’s IPP resulting in R1 storing medications in R1’s room in lieu of consumption as prescribed by R1’s physician. As a result, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED. Citation is issued under Title 22, Division 6 and noted on LIC 9099D.

An exit interview was conducted with Maricon Junson and a copy of this report was provided to Maricor Appeal rights and LIC 811 provided.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20231004110324

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: MELMAR'S GUEST HOME #2	FACILITY NUMBER: 397000250
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/20/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/23/2023 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 was not met as evidenced by:	1 2 3 4 5 6 7	Licensee will ensure completed staff training on proper assisting with self-administration of medications. Training to include, but not be limited to: Procedural method to ensure residents take medication as prescribed. Training to be conducted by outside vendor. Training date to be submitted to LPA by POC due date. Proof of completed training to be submitted to LPA by 11-11-23.
	8 9 10 11 12 13 14	Based on interview and record review, facility staff did not take appropriate steps to ensure R1 took medications as prescribed. This posed an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 10/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

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
10/04/2023 and conducted by Evaluator Michael Bilger

COMPLAINT CONTROL NUMBER: 27-AS-20231004110324

FACILITY NAME:	MELMAR'S GUEST HOME #2		FACILITY NUMBER:	397000250
ADMINISTRATOR:	CAMERO, MARICOR		FACILITY TYPE:	735
ADDRESS:	6801 MONTAUBAN AVENUE		TELEPHONE:	(209) 683-6876
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95210
CAPACITY:	6	CENSUS: 4	DATE:	10/20/2023
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Maricor Junson		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Staff spit on resident while in care.

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

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

LIC9099 (FAS) - (06/04)

Page: 4 of 4