405802287-9-2-2022-29-AS-KBUY-CHVUM9-20220902154158

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405802287
Report Date: 09/01/2022
Date Signed: 09/02/2022 12:33:58 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
06/16/2021 and conducted by Evaluator Mark Jeffries

COMPLAINT CONTROL NUMBER: 29-AS-20210616113119

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: 11	DATE:	09/01/2022
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Cristal Cole/Med Tech		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff are not properly trained to administer medications.
Facility is not in good repair.

INVESTIGATION FINDINGS:

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At 12:30pm on 09/01/2022, Licensing Program Analyst (LPA) Jeffries arrived at the facility to deliver final findings to the allegations to this complaint. LPA met withCristal Cole/MedTech announced the reason for the visit.

As to the allegation of, “Staff are not properly trained to give medications.” Based on documentation, interviews, and written requests for training on 05/11/2021, 06/18/2021, and 08/16/2022; the written request on LIC9099’s related to this complaint, and additionally a written request of staff training's related to a different complaint (29-AS-20210505113111) of a similar allegation on 05/11/2021 in the same time period of this complaint:
-On 05/11/2021, per LIC9099, the request of, “Staff training's…” was made on this report, on a different complaint (29-AS-20210505113111) during the same time period.
-On 06/18/2022, per LIC9099, the request of, “staff training records/certifications on medication administration” was made in the content of the report.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark Jeffries	TELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022

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 6

Control Number 29-AS-20210616113119

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: 09/01/2022

NARRATIVE

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-On 08/16/2022 per LIC9099 and LIC9099-C, “-All training records for all staff in 2021 that cover the subject of Dementia care, Medications, Feeding, transfer care, feeding assistance, and Hoyer lift training.” was made on this report.
No training records were produced by the licensee until the date of 08/19/2022, over year and three months past the initial request for records. In this submission of training records, the only record of medication training the Licensee submitted was for staff S4 who had: 1 hour of training in, Minimalizing Medical Errors, dated 09/17/2021; 1 hour of training in, Assisting with self-administration of medication: Guidelines, dated 01/01/2021; 1 hour of training in, Medication Documentation for California, dated 07/19/2022.
All the training listed above was completed after the date of incident related to this complaint, subsequently there is no evidence that any staff was properly trained to administer medications during the time of the allegations to this complaint. Interviews of Staff 1 – 6 confirmed that all staff interviewed passed medication to residents in care and that is a normal practice of the facility. Based on interviews and documentation the allegation of, “Staff are not properly trained to give medication.” Is substantiated at this time. No citation issued on this report, as this was cited today under 29-AS-20210505113111.

As to the allegation of, “Facility is not in good repair.” It was discovered though documentation, interviews, observations, and photographic evidence that the facility floor is in disrepair. It was observed by the Licensing Program Analyst (LPA) Jeffries on 08/16/2022, on the first floor it was observed in the main living/dining/entrance area that several planks of laminate flooring are separating from each other and need repair or replacement. It was observed by LPA on 08/16/2022 that the first bedroom to the right on the first floor also had laminate plank flooring that were separating and in need of repair or placement. On 08/16/2022, LPA observed in the hallway of the first floor several areas where the planking is separated. On 08/16/2022, LPA observed on the second floor kitchen area next to the sink where an attempt to repair the loose laminate planking were screwed in by approximately six wood screws, however the planks were still separated and the floor in an area in front of the sink would fall 1”-3” inches when LPA walked over that area of the floor, approximately 40 square feet of flooring bowed 1”-3” in front of the upstairs sink.

CONTINUED on LIC9099-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark Jeffries	TELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 29-AS-20210616113119

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: 09/01/2022

NARRATIVE

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On 08/16/2022, LPA observed the floor in the upstairs living room towards the center of the living room would also bow 1”-3” up and down when LPA walked over the described area which is approximately 40 square feet. On 08/16/2022, LPA observed several door thresholds throughout the facility being in disrepair and creating a possible tripping hazard for residence in care. On 08/16/2022 LPA observed the door to room 3 on the second floor to be very difficult to open and shut due to miss alignment which may be related to the disrepair of the second story floor as there was no observational evidence of the hinges being bent, broken, or dislocated. All areas observer by LPA are supported with photographic evidence. It was also observed by LPA Chavez on 05/11/2021, that a “water puddle and leak of approximately six (6) inches in diameter in downstairs laundry room floor to the right of sink cabinet” as well as “floor is disrepair” in resident’s room, with provided photographic evidence provided. On 06/16/2021, LPA Chavez noted that she observed the same disrepair's, noted on LIC9099. On 08/16/2022, additionally, LPA Chavez noted “at 12:26 pm, LPA toured the facility and observed the following items in disrepair: … 12:29 pm, in Marty’s room: Closet door off track, not sliding; 12:29 pm, blinds in resident Jeen’s room broken and the floor was in disrepair; 12:37 pm, blinds in resident Lelan’s room broken; 12:49 pm, blinds at end of hall near Mary’s/Marlene’s room broken; 1:38 pm, blinds in hall looking out to pool broken; 12:55 pm, paint chipping in shower in upstairs bathroom near Wilta’s bedroom; 12:45 pm, upstairs kitchen refrigerator light not working; 12:26 pm, water puddle and leak of approximately six (6) inches in diameter in downstairs laundry room floor to the right of sink cabinet; 12:420 pm, door unlocked to upstairs laundry room, child-proof door knob present covering door handle, however, it is not a lock” on LIC812 dated 06/16/2021; On 08/19/2022, Licensees send by email to LPA a profit Loss summary indicating the cost of repairs and maintenance for the time period of January 2019 through June 2021. The only specific repairs noted each year on this summary were of the laundry machines. The other line items on the summary were building repairs, equipment repairs and building maintenance, however there are no specific repairs noted on this summary in those categories that indicated any floor repairs were made, which is all prior to the time frame of this complaint (April 2021 through July 2021). The only observational repairs made were the noted by the Licensee of blinds in the downstairs main room replaced and 6 wood screws noted by LPA on 08/16/2022. Interviews of Staff (S1-S5) provided no evidence that floor repairs were made to the facility and observations made by LPA Chavez on 06/16/2021 and observation made by LPA Jeffries on 08/16/2022 show a facility that is in disrepair. Due to observations, lack of documentation and interviews, the allegation of, “Facility floor is in disrepair.” Is substantiated at this time.
No citation issued on this report, as this was cited today under 29-AS-20210505113111.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark Jeffries	TELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022

LIC9099 (FAS) - (06/04)

Page: 6 of 6

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
06/16/2021 and conducted by Evaluator Mark Jeffries

COMPLAINT CONTROL NUMBER: 29-AS-20210616113119

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: 11	DATE:	09/01/2022
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Cristal Cole/Med Tech		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff handle residents roughly.
Resident sustained injuries while in care.
Staff are losing resident's medications.
Staff do not assist residents in timely manner.
Facility is not reporting incidents.

INVESTIGATION FINDINGS:

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At pm on 09/01/2022, Licensing Program Analyst (LPA) Jeffries arrived at the facility to deliver final findings to the allegations to this complaint. LPA met with Cristal Cole/Med Tech announced the reason for the visit. As to the allegation of, “Staff handled resident roughly.” It was discovered through interviews and documentation that daily resident progress notes were taken of each resident. The progress notes during the time of the allegation to this complaint were reviewed, April 2021 through July 2021. Incident reports submitted by the facility were also reviewed during this period, April 2021 through July 2021. There was no evidence of residents injured by daily progress notes of staff or incident reports submitted by the facility during this time period. Additionally, Residents 1 – 6 who were interviewed were asked if they had been treated or moved roughly by staff at any time during their stay at the facility and no resident had any issues with being treated roughly. Staff were also interviewed and Staff 1 -6 stated that they have never been rough with residents, nor have they witnessed other staff being rough with residents in care at this facility. Based on documentation and interviews there is not enough evidence to support the allegation of, “Staff handle residents roughly.” and is unsubstantiated at this time. CONTINUED LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark Jeffries	TELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022

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

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 29-AS-20210616113119

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: 09/01/2022

NARRATIVE

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As to the allegation of, “Resident sustained injuries while in care.” It was discovered through interviews and documentation that daily resident progress notes were taken of each resident. The progress notes during the time of allegation to this complaint were reviewed, April 2021 through July 2021. Incident reports submitted by the facility were also reviewed during this period, April 2021 through July 2021. There was no evidence of residents injured by rough handling by daily progress notes of staff or incident reports submitted by the facility during this time period. Additionally, Residents 1 – 6 who were interviewed were asked if they had been treated or moved roughly by staff at any time during their stay at the facility and no resident had any issues with being treated roughly. Staff were also interviewed and Staff 1 -6 stated that they have never been rough with residents, nor have they witnessed other staff being rough with resident in care at this facility. Based on documentation and interviews there is not enough evidence to support the allegation of, “Resident sustained injuries while in care.” and is unsubstantiated at this time.

As to the allegation of, “Staff are losing resident’s medications.” Based on interviews and documentation there was insufficient evidence to determine any missing medications during the time frame of this complaint, April 2021 through July of 2021. Medication Administration Records reviewed did not show any evidence of medication missed or destroyed for any resident residing in the facility during this time. There were no incident reports of medication missing by the facility during this time period. A physical medication audit was not capable of being conducted to determine an exact medication count during the time of the allegation. All interviews of staff (S1-S5) and residents (R1-R6) were inconclusive of any credible recollection of loss of any medication during this time. Due to lack to evidence, the allegation of, “Staff are losing resident’s medications.” is unsubstantiated at this time.

As to the allegation of, “Staff do not assist residents in timely manner.” It was discovered through interviews and documentation that staff document daily progress of residents. Progress reports of residents during the time of April 1, 2021 through June 1st of 2021 do not indicate any instance of residents needs not being met in a timely manner. Interviews of Residents 1 – 6 did not reveal that any of the residents do not have an issue with being assisted in a timely manner. Interviews of 4 of 5 staff did not indicate that residents had to wait to be assisted. At this time there is not enough evidence to support the allegation of, “Staff do no assist resident in timely manner.” and is unsubstantiated at this time.

CONTINUED on LIC9099-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark Jeffries	TELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 29-AS-20210616113119

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: 09/01/2022

NARRATIVE

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-Facility is not reporting incidents. –
As to the allegation of, “Facility is not reporting incidents.” It was discovered through documentation, house notes, incident reports and interviews. That during the time of May 1, 2021, through June 23, 2021, there were daily house notes taken of resident daily progress. LPA reviewed house notes of each day in May and June of 2021 and compared those progress notes to the Serious Incident Reports (SIR) submitted to Community Care Licensing (CCL) per regulations. LPA noted that there were two incidents reported to CCL during this time frame and the house notes did correspond with the incidents reported in the SIRs. Furthermore, there were no house note that indicated a serious change in a resident’s condition, that needed to be reported to CCL per regulations. Interviews of Staff 1-6 did not indicate that any serious incidents or resident change of condition was failed to be reported during this time frame. Based on documentation and interviews, there is not enough evidence to support the allegation of, “Facility is not reporting incidents.” and is unsubstantiated at this time.

Exit interview, report signed and report emailed.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark Jeffries	TELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022

LIC9099 (FAS) - (06/04)

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