<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 397005738
Report Date: 03/09/2022
Date Signed: 03/09/2022 03:54:08 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
02/25/2022 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20220225105424

FACILITY NAME:INSPIRING CAREFACILITY NUMBER:
397005738
ADMINISTRATOR:PUCKETT, VICTORIAFACILITY TYPE:
735
ADDRESS:2488 NATHANIEL STREETTELEPHONE:
(209) 951-2405
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY:5CENSUS: 4DATE:
03/09/2022
UNANNOUNCEDTIME BEGAN:
09:44 AM
MET WITH:Carrie MumphreyTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility medication records are incomplete
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 3-9-22 at 9:44am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to continue a complaint investigation for the allegation listed above. LPA met with Assistant Administrator Carrie Mumphrey and explained the purpose of the visit. Administrator William Puckett was contacted and gave permission for Carrie to accommodate LPA and sign in his absence. LPA reviewed facility file documentation including Individualized Program Plan (IPP) for resident1 (R1), Individualized Service Plan (ISP) for R1, needs and service plan for R1, medication log sheets for R1, R2, R3, and R4 dated for January 2022, February 2022 and March 2022, centralized medication storage records for R1, R2, R3, and R4 dated January 2022, February 2022 and March 2022. LPA also interviewed Assistant Administrator.

LPA reviewed the medication log sheets for R1, R2, R3, and R4 and a bubble pack medication card for R1. LPA also interviewed Administrator, S1, and complainant. {Cont. on 9099C}
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20220225105424
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: INSPIRING CARE
FACILITY NUMBER: 397005738
VISIT DATE: 03/09/2022
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
 It was revealed through interviews that on 2-17-22 at 5pm, medication was given to R1 but not immediately signed as given on the medication log sheet. It was determined that medication was signed on 2-18-22 to indicate medication may have been dispensed to R1. A review of R1’s bubble pack determined that medication was not in the container for 2-17-22. Based on interviews and record reviews, it is determined that medication logs are signed by staff but not consistently for the month of February for R4. Medication logs for R4 were not complete and missing documentation for 2/28/22. An additional review of January 2022 medication log sheets for R4 revealed additional incomplete documentation for 1/22/22 to 1/24/22 and 1/27/22 to 1/31/22. Log sheets match the accompanying centralized storage medication records.

Based on the interviews and record reviews conducted it is determined that facility contains medication records which are incomplete. Therefore, the preponderance of evidence standard is met and this allegation is SUBSTANTIATED.

Deficiencies are cited on LIC 9099D under Title 22, Division 6. An exit interview was conducted with Carrie Mumphrey and a copy of this report was left with Carrie. Appeal Rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20220225105424
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: INSPIRING CARE
FACILITY NUMBER: 397005738
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/28/2022
Section Cited
CCR
80070(a)(b)(10)
1
2
3
4
5
6
7
Client Records. (a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client. (b) Each record must contain information including, but not limited to, the following:(10) Record of current medications...
1
2
3
4
5
6
7
Licensee will ensure that medication training including importance of documentation for all staff will be completed by POC due date. Licensee to submit proof of completed training to LPA by POC due date.
8
9
10
11
12
13
14
This requirement is not met as evidenced by: Based on observation and interview, medication log sheet for R4 were not complete and missing documentation for medications scheduled from 1-22-22 to 1-24-22 and 1/27/2 to 1/31/22 as well as 2/28/22. This poses a potential 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: 03/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5