405801784-10-3-2022-29-AS-KBUY-CJUSG6-20221003135126

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405801784
Report Date: 10/03/2022
Date Signed: 10/03/2022 09:48:47 AM

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
12/16/2021 and conducted by Evaluator Jeannette Olson

COMPLAINT CONTROL NUMBER: 29-AS-20211216104520

FACILITY NAME:	DIVINE HOME FOR THE ELDERLY I		FACILITY NUMBER:	405801784
ADMINISTRATOR:	CANDIDA SALVADOR		FACILITY TYPE:	740
ADDRESS:	1934 TULIPWOOD DRIVE		TELEPHONE:	(805) 226-0994
CITY:	PASO ROBLES	STATE: CA	ZIP CODE:	93446
CAPACITY:	0	CENSUS: 0	DATE:	10/03/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	N/A		TIME COMPLETED:	09:50 AM

ALLEGATION(S):

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Due to a lack of supervision, medications were accessible to residents

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Olson conducted an investigation into this complaint and is issuing final findings for the above allegation via email and US mail.

On the allegation: Due to a lack of supervision, medications were accessible to residents .

It was alleged on 12/13/2021 that Resident 1 (R1) gave Resident 2 (R2) an insulin injection that was not warranted, while in the facility. R2’s physician’s report dated 12/4/2020 indicated R2 has diabetes, requires insulin based on blood sugar readings, is legally blind, and has dementia and mild cognitive impairment. R1 assisted R2 with their insulin injections at the facility since admission on 1/10/2021, since facility staff were not allowed to give injections. Based on information from a local hospital, on 12/13/2021, R1 gave R2 an insulin shot when R2 did not need it. As a result, R2 was hospitalized with hypoglycemia.
Continued on 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2022

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-20211216104520

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: DIVINE HOME FOR THE ELDERLY I	FACILITY NUMBER: 405801784
	VISIT DATE: 10/03/2022

NARRATIVE

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On 12/17/2021, LPA interviewed R1, who was unsure about medications, even though doctor’s notes indicate R1 is handling R2’s medications. R1 stated they checked R2’s glucose every evening and would give insulin if it measured over 250. Staff 1 (S1) stated R1 gets confused and S1 would try to supervise R1 regarding R2’s medications. When R2 returned from the hospital, they took the insulin and needles away from R1.

Regulation 87629- Injections indicates that the licensee can accept or retain a resident who requires injections, if the resident or an appropriately skilled professional administers the injections. It also indicates licensees who admit or retain residents who require injections are responsible to ensure injections are administered by as appropriately skilled professional should the resident require assistance. Community Care Licensing's Medications Guide version 8/30/2021 indicates only the resident who requires an injection or an appropriately skilled medical professional can administer an injection, not a family member.

Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D).

Exit interview conducted, appeal rights discussed, and a copy of this report issued.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 29-AS-20211216104520

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: DIVINE HOME FOR THE ELDERLY I	FACILITY NUMBER: 405801784
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/03/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/03/2022 Section Cited CCR 87629(b)(1)	1 2 3 4 5 6 7	87629(b)(1) Injections…licensees who admit or retain residents who require injections shall be responsible for the following: Ensuring that injections are administered by an appropriately skilled professional should the resident require assistance.	1 2 3 4 5 6 7	Facility is closed
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above when an appropriately skilled professional did not assist R2 with insulin injections, which posed an immediate 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.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2022

LIC9099 (FAS) - (06/04)

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