405850052-12-1-2023-29-AS-KBUY-CYQ4HC-20231220180654

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405850052
Report Date: 12/01/2023
Date Signed: 12/01/2023 10:56:53 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
05/17/2023 and conducted by Evaluator Rachael De Leon

COMPLAINT CONTROL NUMBER: 29-AS-20230517162207

FACILITY NAME:	PARK PLACE ASSISTED LIVING		FACILITY NUMBER:	405850052
ADMINISTRATOR:	BARNHILL, DIANA		FACILITY TYPE:	740
ADDRESS:	7500 PORTOLA RD		TELEPHONE:	(805) 591-9855
CITY:	ATASCADERO	STATE: CA	ZIP CODE:	93422
CAPACITY:	13	CENSUS: 12	DATE:	12/01/2023
		UNANNOUNCED	TIME BEGAN:	10:27 AM
MET WITH:	CareStaff		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Staff did not provide medications as prescribed.
Staff did not assist with medications refills in a timely manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above to deliver final findings. LPA met with Care Staff and explained the purpose of the visit. LPA spoke with Administrator/Licensee by phone and LPA will have staff sign report.

LPA De Leon conducted the initial 10-day complaint visit to the facility on 05/22/2023, conducted interviews at 10:00am, reviewed records and requested copies of records. LPA De Leon interviewed witness at 4:54pm on 05/22/2023. On 05/23/2023 LPA De Leon received additional medication records. LPA De Leon reviewed all medication records on 11/18/2023 and requested additional records. LPA De Leon reviewed additional records on 11/20/23, 11/22/2023 and 11/27/2023.

On the allegation: Staff did not provide medications as prescribed. LPA De Leon reviewed Medications records for R1 which revealed 2 medications Timolol and Latanoprost were not being ordered monthly.
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: 12/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023

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-20230517162207

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: PARK PLACE ASSISTED LIVING	FACILITY NUMBER: 405850052
	VISIT DATE: 12/01/2023

NARRATIVE

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Medication Timolol Mal Sol 0.5% OP 15ml bottle expired approximately 1 year after order date according to the Pharmacy Model Drug. The facility Centrally Stored Medication and Destruct Record (CSMDR) showed Timolol medication logged in for the months of April, July, November of 2022 and February, March of 2023. The facility Medication Administrator Record (MAR) shows medication Timolol listed from April 2022-March 2023 being given daily in 1 eye 2x’s per day as prescribed by the doctor. The Timolol medication ordered in July 2022 and then ordered in November of 2022 would not have provided enough medication to fill the requirements of the prescription order of 1 eye 2x’s per day. The Medication Latanoprost Sol 0.005% 2.5ml bottle needed to be discarded 6 weeks after the bottle was opened according to the Pharmacy Model Drug. The facility CSMDR record showed Latanoprost logged in for the months of May, June- 2x’s, July of 2022 and February, March 2023. The facility MAR showed the medication Latanoprost given in 1 eye 1 time per day from April 2022-March 2023 as prescribed by the doctor. The Latanoprost 2.5 ml bottle will last approximately 30 days according to the Pharmacy Model Drug and the medication needs to be discarded 6 weeks after opening the bottle. Medication Latanoprost would have needed to be ordered and logged on to the CSMDR every 6 weeks to be able to fill the doctor’s order and not be expired while using. The pharmacy Model Drug payment invoices showed there were no re-orders for Latanoprost in August, September, October, November, or December of 2022 and January of 2023. LPA reviewed the medication orders/invoices from Pharmacy Model Drung which showed Timolol was ordered on 04/07/22, 07/25/22, 11/15/22, 02/24/2023, 03/18/2023, and the medication showed Latanoprost was ordered on 04/06/22, 05/17/22, 06/20/22, 07/25/22, 02/24/23, and on 03/18/23. Based on the evidence this allegation is deemed Substantiated at this time.

On the allegation: Staff did not assist with medications refills in a timely manner. LPA reviewed the medication order/invoices from the Pharmacy Model Drug which showed medications were not ordered monthly. The medication Timolol was not ordered in the months of May, June, August, September, October, December of 2022, and January of 2023. The medication Latanoprost was not ordered in August, September, October, November, December of 2022, and January of 2023. The medications were not being ordered to fill the doctor’s prescriptions orders or enough of the medication Latanoprost for it to not to be expired while using. Based on the evidence this allegation is deemed Substantiated at this time.

Exit interview conducted, deficiency issued, copy of report and appeal rights printed for Licensee/Administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 29-AS-20230517162207

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: PARK PLACE ASSISTED LIVING	FACILITY NUMBER: 405850052
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/01/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/08/2023 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	(a)...The plan...provide assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Administrator agreed to hold staff training for all staff handling medications on regulation 87465, CCL Medication Guide, and facility policy and procedures for handling and reordering medications, audit medications for expiration dates, provide an up-to-date LIC 500 with training documents and staff signatures to CCL.
	8 9 10 11 12 13 14	Based on record review the licensee did not comply with the regulation above R1’s medications was not being reordered as often as needed and one medication was being used after it expired which poses a 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: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023

LIC9099 (FAS) - (06/04)

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