405801050-10-7-2021-29-AS-KBUY-C88LX7-20211028090817

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405801050
Report Date: 10/07/2021
Date Signed: 10/07/2021 04:22:06 PM

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
01/22/2020 and conducted by Evaluator Rachael De Leon

COMPLAINT CONTROL NUMBER: 29-AS-20200122152857

FACILITY NAME:	FIVE CITIES RESIDENCE		FACILITY NUMBER:	405801050
ADMINISTRATOR:	PATACSIL, CAROLINA G.		FACILITY TYPE:	740
ADDRESS:	472 DIXSON STREET		TELEPHONE:	(805) 489-3481
CITY:	ARROYO GRANDE	STATE: CA	ZIP CODE:	93420
CAPACITY:	6	CENSUS: 5	DATE:	10/07/2021
		UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	I Enos Patacsil, Licensee		TIME COMPLETED:	04:21 PM

ALLEGATION(S):

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Staff failed to administer medication to resident.
Staff over medicated resident
Facility illegally evicted resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit on 10/07/2021 to deliver final findings on the complaint allegations. LPA met with Enos Patascil and explained the purpose of the visit.

LPA interviewed staff on 01/31/2020 around 1:00pm, interviewed witnesses on 06/22/2021 at 11:03 am, 2:22 pm and around 4:00 pm. LPA collected records/documentation on 01/31/2020, 09/23/2021, 09/24/2021 and reviewed on 10/04/2021.

On the allegation: Staff failed to administer medication to resident. LPA reviewed records and documentation which revealed on 12/26/2021 that staff did not assist with self-administration of two 8:00 am doctor prescribed medications. Based on the evidence this allegation is deemed Substantiated at this time.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021

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-20200122152857

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: FIVE CITIES RESIDENCE	FACILITY NUMBER: 405801050
	VISIT DATE: 10/07/2021

NARRATIVE

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On the allegation: Staff over medicated resident. LPA reviewed medication records and documentation for R1 which revealed that on 11/21/2021 a medication change occurred and R1 should have only received 100 mg of a doctor prescribed medication 3 x’s a day but R1 received one 50 mg one time in the am and 100 mg tabs three times that day of the same medication. On 11/21/2019 a medication change was made by the Physician for a single dose of medication to be given at noon daily instead of 5pm daily and on 12/01 and 12/02 the medication was given at 5:00pm instead of noon on those days. Facility records note R1 to be lethargic on 12/24/2019 and 12/26/2019 but continued to give a Prescribed when needed medication (PRN) for patient safety due to agitation, aggression and restlessness three times on the 24th and 1 time on the 26th and listed the reason of R1 being restless. Based on the evidence the allegation is deemed Substantiated at this time.

On the allegation: Facility illegally evicted resident. LPA interviewed staff and witnesses which revealed Facility staff told witnesses on 12/20/2019 R1 needed to move out of the facility due to behaviors, agitation, aggression, restlessness, and safety. Facility recommended a locked facility for relocation. Facility did not provide any written eviction
notice, paperwork or relocation information to R1 or R1’s responsible party. Facility had only submitted one incident report on R1 and it was not related to R1’s behaviors. R1 did not return to the facility after discharge from a hospital admit on 12/26/2019. Based on the evidence this allegation is deemed Substantiated at this time.

Exit interview, deficiencies cited, copy of report and appeal rights emailed to Licensee.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20200122152857

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: FIVE CITIES RESIDENCE	FACILITY NUMBER: 405801050
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/07/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/11/2021 Section Cited CCR 87465(d)(1-3)	1 2 3 4 5 6 7	...(3)The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record. The requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee agreed to read, review and train all staff on Regulation 87465 and provide proof and signatures to CCL.
	8 9 10 11 12 13 14	Based on record review Licensee did not comply as medications were not given or given without accurate contact and information which poses an immediate Health and Safety risk to residents in care.	8 9 10 11 12 13 14
Type B 10/14/2021 Section Cited ILS 87224(a)	1 2 3 4 5 6 7	87224 Eviction Procedures ...Thirty (30) days written notice to the resident is required...This requirement was not met as evidence by:	1 2 3 4 5 6 7	Licensee’s agreed to read and review Regulation 87224 Evictions Procedures and train all staff that provide notices on the proper way to evict residents in care and the requirements of the regulation provide proof to CCL.
	8 9 10 11 12 13 14	Based on interview with Witnesses Licensee did not comply as no written notice of eviction was given to R1 which poses a potential personal right risk to residents in care.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021

LIC9099 (FAS) - (06/04)

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