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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405800830
Report Date: 07/13/2022
Date Signed: 07/13/2022 03:26:48 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
07/07/2022 and conducted by Evaluator Darlene Chavez
COMPLAINT CONTROL NUMBER: 29-AS-20220707123506
FACILITY NAME:AMERICAN CARE HOMEFACILITY NUMBER:
405800830
ADMINISTRATOR:LIXIA ZHANGFACILITY TYPE:
735
ADDRESS:1240 EL CAMINO REALTELEPHONE:
(805) 466-9029
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY:38CENSUS: 35DATE:
07/13/2022
UNANNOUNCEDTIME BEGAN:
01:21 PM
MET WITH:Lixia Zhang, Licensee/AdministratorTIME COMPLETED:
03:50 PM
ALLEGATION(S):
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Staff are not dispensing resident prescribed medication
INVESTIGATION FINDINGS:
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On 7/13/2022 at 1:21 pm, Licensing Program Analyst (LPA) Darlene Chavez conducted an unannounced 10-day complaint visit to the facility listed above. LPA met with Lixia Zhang, Licensee/Administrator, and informed of the reason for the visit.

On the allegation, “Staff are not dispensing resident prescribed medication,” the complainant’s concern was that Resident #1 (R1) was not being given PRNs for pain upon request. To investigate the allegation, LPA interviewed the licensee, attempted to interview the complainant, and reviewed documentation.

LPA reviewed Medication Administration Records (MARs) for Resident #1 (R1) for June and July 2022. R1 was given four PRNs for pain management on 7/6/22 and 7/7/22 and two PRNs on 6/2/22, four PRNs on 6/4/22, 6/5/22, one on 6/8/22, and four on 6/29/22 and 6/30/22. Administrator states that R1 has not requested PRNs on any other days in July 2022.
Continued on 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2022
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 2
Control Number 29-AS-20220707123506
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: AMERICAN CARE HOME
FACILITY NUMBER: 405800830
VISIT DATE: 07/13/2022
NARRATIVE
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Facility sent an incident report for an incident on 1/31/22 saying that R1 requested and was given PRNs. Another incident report was sent regarding an incident on 3/21/22 stating that R1 refused morning medications and stated that R1 did not need them because R1’s “cannabis doctor says R1 does not need medication” and that R1’s “lawyer told R1 not to take medication.” Licensee stated that R1 did not have a cannabis doctor nor lawyer. LPA reviewed R1’s file and there was no documentation from a cannabis doctor nor lawyer.

Based on evidence obtained, the allegation “Staff are not dispensing resident prescribed medication,” is deemed Unsubstantiated at this time. Records indicate R1 is receiving PRNs for pain management. No deficiency cited.

Exit interview conducted and a copy of the report emailed to licensee.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2