405802287-10-9-2020-29-AS-KBUY-BUCSZ7-20201013141840

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405802287
Report Date: 10/09/2020
Date Signed: 10/09/2020 03:23:01 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
02/07/2020 and conducted by Evaluator Mark Jeffries

COMPLAINT CONTROL NUMBER: 29-AS-20200207165337

FACILITY NAME:	GARDEN VIEW INN		FACILITY NUMBER:	405802287
ADMINISTRATOR:	KOC DE JONG, DIMFNA		FACILITY TYPE:	740
ADDRESS:	7105 SAN GABRIEL RD		TELEPHONE:	(805) 462-2273
CITY:	ATASCADERO	STATE: CA	ZIP CODE:	93422
CAPACITY:	15	CENSUS:	DATE:	10/09/2020
		UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Dimfna Koc De Jung/Administrator		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff was under the influence of alcohol while caring for residents.

Staff stole residents' medication.

Staff did not report unusual incident to appropriate agencies.

INVESTIGATION FINDINGS:

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

At 3:30pm, on 10 /09 /2020, Licensing Program Analyst (LPA) Mark Jeffries presented final finding as to the allegations listed on this complaint. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Licensee Dimfna Koc De Jong.

As to the allegation of, “Staff was under the influence of alcohol while caring for residents.” Interviews of 7 of 10 staff, 5 of 11 residents and Administrator/Licensee resulted in conflicting accounts from staff as to allegation of S5 being under the influence of alcohol while caring for residents; LPA noted that staff that worked same shift (S6 and S7) as S5 did not believe that S5 was drinking on or before any shift as well as S3 and S4, who worked the shift before S5 did not believe that S5 was under the influence of alcohol while caring for residents;

CONTINUED on LIC9099-C

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: 10/09/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2020

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-20200207165337

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: GARDEN VIEW INN	FACILITY NUMBER: 405802287
	VISIT DATE: 10/09/2020

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

Interview of residents (R2, R3, R4, and R5) were unable to reach a determination of S5 being under the influence of alcohol while caring for residents and R1 did not believe that S5 was under the influence of alcohol while caring for residents. There was no admission and adamant denial by S5 as to drinking alcohol before or during scheduled work at the facility. Licensee stated that S5 was never under the influence while at the facility and caring for residents. LPA was not able to collect any significant evidence that could conclusively determine if S5 was drinking while caring for residents. Due to the lack of supporting evidence, the allegation of, “Staff was under the influence of alcohol while caring for residents.” is unsubstantiated, at this time.

As to the allegation of, “Staff stole residents' medication.” Investigation interviews and collection of medication documentation resulting in a comprehensive medication audit of the resident 6 (R6) medications, who was identified as the resident whose medication were being stolen. The comprehensive audit reviewed all medication documentation from January 2019 to April 2019, the time S5 had access to medications, and was distributing medication, as the allegation stated; During that time period, no discrepancy was discovered in the medication audit. Because the allegation was made 6 months after S5 had access to medication cart, a physical audit of R6’s medication was not possible to compare to the medication logs audit. Interviews of 7 of 11 staff provided no evidence of S5 stealing resident’s medication. Interviews of 5 of 11 residents did not result in any evidence of S5 stealing medication. Based on medication documentation, interviews and lack to physical evidence, there is not enough evidence to support the allegation of, “Staff stole residents' medication.” Therefore, the allegation is unsubstantiated, at this time.
Staff did not report unusual incident to appropriate agencies.
As to the allegation of, “Staff did not report unusual incident to appropriate agencies.” Interviews, documentation and records that resulted from this complaint determined that there was no incident that went unreported that pertained to this investigation. There was no unusual incident to report to appropriate agencies therefore, the allegation of “Staff did not report unusual incident to appropriate agencies.” Is unsubstantiated, at this time.

A telephonic exit interview was conducted with Licensee, and a hard copy was provided via email for signature.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark Jeffries	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 2