405800142-9-30-2024-29-AS-KBUY-D9LS94-20240930134007

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405800142
Report Date: 09/03/2024
Date Signed: 09/30/2024 01:36:20 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/22/2024 and conducted by Evaluator Erika Miller

COMPLAINT CONTROL NUMBER: 29-AS-20240122095800

FACILITY NAME:	CASA DE FLORES		FACILITY NUMBER:	405800142
ADMINISTRATOR:	JONATHAN D. ROBERTS		FACILITY TYPE:	741
ADDRESS:	1405 TERESA DRIVE		TELEPHONE:	(805) 772-7372
CITY:	MORRO BAY	STATE: CA	ZIP CODE:	93442
CAPACITY:	120	CENSUS: 77	DATE:	09/03/2024
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Jonathan Roberts, Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff interfered with a resident's medical decisions
Staff mishandled a resident's medications while in care
Facility Staff failed to provide requested records to designated representative
Facility staff failed to provide current medical information to emergency responders

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Miller made a subsequent visit to facility on September 3, 2024, to deliver complaint findings. LPA met with Administrator and explained the purpose of the visit. LPAs Olson and Miller conducted an unannounced initial complaint visit to the facility above on January 30, 2024. LPA interviewed staff and residents and obtained relevant documentation.

On the allegation: Staff interfered with a resident's medical decisions. It was alleged that Staff changed pharmacy of choice without resident’s (R1) consent. It was alleged that residents have a limited choice in home health services. LPAs Miller and Olson interviewed residents from 1:29 p.m. to 2:35 p.m.
The majority of residents interviewed stated that they did not experience staff interference with medical decisions. One resident could not explain how staff was interfering with their medical decisions. None of the residents expressed any concerns about a limited choice in home health services.
(Continued on 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika Miller	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 09/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2024

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 29-AS-20240122095800

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CASA DE FLORES	FACILITY NUMBER: 405800142
	VISIT DATE: 09/03/2024

NARRATIVE

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Staff (S1) stated that dementia residents are not accepted at the facility. S1 stated that R1 makes their own decisions and confirmed that R1 does not use a cane. S1 stated that there is no obligation to contact the POA for any reason. S1 stated that once residents no longer have mental faculties to make decisions, they may no longer reside at facility. S1 further stated that no prescriptions were delivered from Pill Save to R1. Administrator stated that at no time was R1’s prescription order transferred to Pill Save. Administrator provided prescription order packing slips from Model Drug orders during the period of September 25, 2023, through November 24, 2023. R1’s prescriptions continued to be delivered from Model Drug. There is no evidence to support that R1 prescriptions were filled by Pill Save.

Administrator stated that they spoke to residents about using the facility’s preferred pharmacy, Pill Save, as it is it is a local pharmacy that provides 24 hour delivery and more responsive customer service. Administrator stated that a care conference was arranged with residents to express their complaints or concerns. Administrator spoke with residents as well as primary care providers. Administrator stated approximately 40% of residents rolled their prescription order to Pill Save. Administrator stated that residents that wanted to change their pharmacy did so in writing. It was verbally verified that roll-over could take up to a week.

Administrator further stated that he provides residents with a menu of 5 local Home Health Services options, but there is no obligation to choose from the 5 presented.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated.

On the allegation: Staff mishandled a resident's medications while in care.

It was alleged that staff did not follow doctor’s order on prescriptions as R1 was overly medicated and that lorazepam should have been discontinued. It was alleged that the Medication Administration Record (MAR) Reports reflect a sedative was prescribed as a PRN and was not properly recorded by Med Techs.

LPA Miller conducted a review of documents including a physician’s letter dated 10/30/2023, requesting that R1 discontinue lorazepam. This request was notated in R1’s file. LPA reviewed all medications in cart for Resident 1 and compared it to the MAR. There is no record of lorazepam being administered to R1 during the period of November 2023 through February 2024 or being over medicated. LPA observed a printout in R1’s file from a hospital visit on 12/20/23 from Sierra Regional Medical Center. (Continued on 9099-C)

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika Miller	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 09/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2024

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20240122095800

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CASA DE FLORES	FACILITY NUMBER: 405800142
	VISIT DATE: 09/03/2024

NARRATIVE

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The printout lists current medications that included the lorazepam, as the hospital had a list of old medication orders on file. There was no evidence to indicate the facility provided lorazepam to R1 after the medication was discontinued.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated.

On the allegation: Facility Staff failed to provide requested records to designated representative.
It was alleged that Staff did not provide all records as requested by responsible party. Responsible party confirmed they received documents from the facility, but did not feel it was complete based on the number of documents provided. Administrator stated that all requested records were provided to the responsible party. Administrator was unclear what additional documents were being requested. Administrator stated the responsible party acknowledged receipt of the records in December 2023 and no further requests were made.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated.

On the allegation: Facility staff failed to provide current medical information to emergency responders.
It was alleged that Staff sent R1 to the hospital with an outdated Physician Order for Life-Sustaining Treatment (POLST). During the initial visit, Staff 1 reviewed the emergency services binder at the front desk and R1 did not have a POLST in the file. Staff 1 then reviewed R1’s file and found that R1 had two different POLSTs, but the directives indicated were identical. Administrator stated they remove outdated POLSTs from resident files, to ensure only the most current is in the file. LPA reviewed a copy of R1’s POLST dated 12/18/2023 and only observed one POLST on file.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated.

An Exit interview conducted and a copy of this report issued.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika Miller	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 09/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2024

LIC9099 (FAS) - (06/04)

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