405801283-9-9-2022-29-AS-KBUY-CJ4SG7-20220909135127

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405801283
Report Date: 09/09/2022
Date Signed: 09/09/2022 01:35:58 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, 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
10/04/2021 and conducted by Evaluator Rachael De Leon

COMPLAINT CONTROL NUMBER: 29-AS-20211004084235

FACILITY NAME:	ALDER HOUSE		FACILITY NUMBER:	405801283
ADMINISTRATOR:	TODD TOSE		FACILITY TYPE:	740
ADDRESS:	295 ALDER STREET		TELEPHONE:	(805) 489-1266
CITY:	ARROYO GRANDE	STATE: CA	ZIP CODE:	93420
CAPACITY:	32	CENSUS:	DATE:	09/09/2022
		UNANNOUNCED	TIME BEGAN:	12:40 PM
MET WITH:	Todd Tose, Administrator		TIME COMPLETED:	01:21 PM

ALLEGATION(S):

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Staff are not dispensing medication as prescribed
Staff are not treating resident with respect

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to deliver final findings of the complaint investigation. LPA met with Administrator Todd Tose and explained the purpose of the visit.

LPA interviewed staff on 10/12/2021 around 11:15 am, 12:00 pm, 12:10 pm, 12:20 pm, on 10/21/2021 at 10:07 AM, 4:13 pm and on 10/22/2021 at 1:53 pm. LPA interviewed witnesses on 10/12/2021 around 11:50 am and on 10/21/2021 at 3:15 pm. LPA interviewed residents on 10/12/2021 12:25 pm and 12:30 pm. LPA requested documentation on 10/12/2021 at 11:15 am. LPA De Leon reviewed facility records on 10/12/2021 around 5:30 pm and reviewed records again on 09/08/2022.
Continued 9099-C

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: 09/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2022

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-20211004084235

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: ALDER HOUSE	FACILITY NUMBER: 405801283
	VISIT DATE: 09/09/2022

NARRATIVE

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On the allegation: Staff are not dispensing medication as prescribed. LPA conducted interviews with 3/6 staff (S1)(S5)(S6) which revealed on the PM shift Resident 1 (R1) was given a PRN medication that was not documented and given disguised in water without a doctor’s order by Staff 8 (S8). Facility internal investigation revealed S8 gave R1 medication on one occasion by camouflaging it in water without a doctor’s order and on another occasion S7 gave R1 medication and did not record it on the medication records. Facility determined conclusive findings and let S8 go from employment. LPA reviewed medications records which were not completed for the dispensing of this medication. Based on the evidence the allegation is deemed Substantiated at this time.

On the allegation: Staff are not treating resident with respect. LPA conducted interview with staff 6 (S6) witnessing S8 giving R1 medication when R1 was refusing and did not want to take the medication, R1 immediately wiped out R1’s mouth when given the medication due to R1 not wanting to take the medication. Facility internal investigation revealed S8 gave R1 medication when R1 was refusing medication. Facility determined conclusive findings and let S8 go from employment. LPA reviewed medication records which were not completed for the dispending of this medication. Based on the evidence the allegation is deemed Substantiated at this time.

Exit interview conducted, deficiencies cited, copy of report and appeal rights emailed to the Administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2022

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20211004084235

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: ALDER HOUSE	FACILITY NUMBER: 405801283
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/09/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/12/2022 Section Cited CCR 87465(a)(5)(D)	1 2 3 4 5 6 7	(a)...(5)...(D)Assistance with self-administration does not include ...camouflaging...resident's right to refuse to take a medication. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator agreed to re-train all staff in regulation 87465 and all medication staff be re-trained in Medication procedures and provide proof of training with all staff signatures and an up to date LIC 500.
	8 9 10 11 12 13 14	Based on interviews and records the Licensee did not comply with the regulation above R8 camouflaged R1’s medication in water without a doctors order and did not record it on the MAR which poses a potential health, safety and personal rights risk to residents in care.	8 9 10 11 12 13 14
Type B 09/16/2022 Section Cited CCR 87468.1(a)(1)	1 2 3 4 5 6 7	(a)...the following personal rights(1)To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator agreed to re-train all staff in regulation 87468, 87468.1 and 87468.2 and provide proof of training with staff signatures and an up to date LIC 500.
	8 9 10 11 12 13 14	Based on interview the Licensee did not comply with the regulation above, S8 did not respect R1’s medication refusal, R1 wiped medication out of R1’s mouth after being forced to take it which poses an immediate Personal Rights 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: 09/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2022

LIC9099 (FAS) - (06/04)

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