405801962-8-3-2021-29-AS-KBUY-C7D2WE-20210930174526

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405801962
Report Date: 08/03/2021
Date Signed: 08/03/2021 04:55:25 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
06/29/2021 and conducted by Evaluator Mark Jeffries

COMPLAINT CONTROL NUMBER: 29-AS-20210629102200

FACILITY NAME:	SINGLETREE CARING HANDS		FACILITY NUMBER:	405801962
ADMINISTRATOR:	HERBERT SALAMANCA		FACILITY TYPE:	740
ADDRESS:	1789 SINGLETREE COURT		TELEPHONE:	(805) 439-1119
CITY:	SAN LUIS OBISPO	STATE: CA	ZIP CODE:	93405
CAPACITY:	6	CENSUS: 5	DATE:	08/03/2021
		UNANNOUNCED	TIME BEGAN:	08:29 AM
MET WITH:	Administrator/Licensee/HERBERT SALAMANCA		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff mismanaged resident's medication.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

At 8:19am on 08/03/2021, Licensing Program Analyst (LPA) Mark Jeffries called Administrator Herbert Salamanca to screen for COVID-19 proticals. At 8:29am LPA arrived at facility and snnouced the reason for the visit was to conculde finial findings for the allegations listed above, which inclede a medication audit of R1 and R2.

As to the allegation of, “Staff mismanaged residents’ medication.” On 08/03/2021 at 9:59am Licensing Program Analyst (LPA) Jeffries and Administrator/Licensee of the facility conducted a thorough medication audit of R1 and R2 medications, Centrally Stored Medication log, and Medication Administration Record (MAR) logs. The medication audit found the following: The medication for R1, Amlodipine, 5mg, taken 1 PO daily, was not filled and had zero tablets, additionally, the Centrally Stored Medication log last entry for this medication was dated a start date of 06/03/2021 with a quantity of 30 tablets, the medication bottle for this medication that was presented (and photographed) to the LPA with no label (label had
CONTINUED on LIC9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark Jeffries	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021

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 5

Control Number 29-AS-20210629102200

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: SINGLETREE CARING HANDS	FACILITY NUMBER: 405801962
	VISIT DATE: 08/03/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

been ripped off the bottle) and therefore could not be validated. According to the Centrally Stored Medication Record, the most recent start date of the medication was 06/03/2021, and according to the MAR the last time the medication was administered was 08/01/2021. Due to the above medication error conducted in the medication audit of R1 and R2 it is determined that the allegation of, “Staff mismanaged residents’ medication.” Is substantiated, at this time.

Exit Interview, Citation issued, appeal rights and report emailed.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark Jeffries	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 5

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
06/29/2021 and conducted by Evaluator Mark Jeffries

COMPLAINT CONTROL NUMBER: 29-AS-20210629102200

FACILITY NAME:	SINGLETREE CARING HANDS		FACILITY NUMBER:	405801962
ADMINISTRATOR:	HERBERT SALAMANCA		FACILITY TYPE:	740
ADDRESS:	1789 SINGLETREE COURT		TELEPHONE:	(805) 439-1119
CITY:	SAN LUIS OBISPO	STATE: CA	ZIP CODE:	93405
CAPACITY:	6	CENSUS: 5	DATE:	08/03/2021
		UNANNOUNCED	TIME BEGAN:	08:29 AM
MET WITH:	Administrator/Licensee/HERBERT SALAMANCA		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff failed to follow residents' prescribed diet plans.
Facility is not ensuring resident obtains necessary medical equipment.
Facility does not have adequate supplies to care for residents.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

At 8:19am on 08/03/2021, Licensing Program Analyst (LPA) Mark Jeffries called Administrator Herbert Salamanca to screen for COVID-19 protocols. At 8:29am LPA arrived at facility and announced the reason for the visit was to conclude finial findings for the allegations listed above, which include a medication audit of R1 and R2.

As to the allegation of, “Staff failed to follow residents’ prescribed diet plans.” On 07/02/2021 at 8:40am, and on 08/03/2021 at 8:30am, Licensing Program Analyst (LPA) Jeffries observed and took photographs of Resident 1, 2, 3 and 4’s breakfast. Both R1 and R2’s breakfast followed the prescribed dietary restrictions as stated in the Hospice Physicians Orders dated 07/07/2021 which both read, “Soft, chopped diet with nectar thick liquids” for R1 and “Soft, chopped diet as tolerated with nectar thick liquids.” For R2. Interviews of R1-R4 and staff revealed no issues with prescribed diets of any of the residents in care.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark Jeffries	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 29-AS-20210629102200

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: SINGLETREE CARING HANDS	FACILITY NUMBER: 405801962
	VISIT DATE: 08/03/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Through interviews, observation, photographic evidence and documentation it was determined that R1 and R2 are receiving diets as prescribed by their physicians. Therefore, the allegation of, “Staff failed to follow residents’ prescribed diet plans.” is unsubstantiated, at this time.

As to the allegation of, “Facility is not ensuring resident obtains necessary medical equipment.” On 07/02/2021, LPA observed the nebulizer for R1 placed on a chair in the Living room area of the facility and R1’s oxygen machine place in a bedroom of R1. During the medication audit it was determined that the nebulizer medication was being used as prescribed and there was no evidence at the time of investigation that R1 did not have necessary medical equipment. On 08/03/2021 at 8:35am LPA observed R1’s nebulizer and oxygen machine in R1’s bedroom readily available for R1’s use. Interviews with R1 did not reveal any issues with use of medical equipment. Therefore, the allegation of, “Facility is not ensuring resident obtains necessary medical equipment.” is unsubstantiated, at this time.

As to the allegation of, “Facility does not have adequate supplies to care for residents.” On July 7th at 8:30am. LPA toured the facility with Administrator/Licensee. LPA observed staff with mask and gloves while working. During the facility tour LPA observed 4 boxes of latex gloves, 4 boxes of N95 masks and several pack of cloth masks in the facilities Personal Protective Equipment (PPE) along with sanitary cleaning supplies in the facilities inventory. On July 2, 2021 at 1:52pm, the Administrator/Licensee also provided photographic evidence of additional PPE stored at 1 of 3 residential care facilities for the elderly (RCFE) that they own, as a centrally stored inventory for all 3 RCFE’s. Due to the PPE being utilized by the staff working and having minimal inventory on hand at this facility, supported by a supply of centrally stored PPE at a different facility, the allegation of, “Facility does not have adequate supplies to care for residents.: is unsubstantiated at this time.
Exit interview, report singed and emailed.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark Jeffries	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 29-AS-20210629102200

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: SINGLETREE CARING HANDS	FACILITY NUMBER: 405801962
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/03/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/10/2021 Section Cited CCR 87465(e)	1 2 3 4 5 6 7	87465(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication.... Based error	1 2 3 4 5 6 7	Licensee will develop and train facility staff on a new redundancy medication distribution policy. Licensee will proved new medication policy by 08/10/2021 to LPA.
	8 9 10 11 12 13 14	discovered during the medication audit of R1 there was no record of the mediciton in question for the month of July 2021, which poses a potential 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: Mark Jeffries	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021

LIC9099 (FAS) - (06/04)

Page: 5 of 5