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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601039
Report Date: 11/08/2024
Date Signed: 11/08/2024 01:29:36 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/07/2024 and conducted by Evaluator Jaime Vado
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20241007215642
FACILITY NAME:CADENCE MILLBRAEFACILITY NUMBER:
415601039
ADMINISTRATOR:JOAN NEWMANFACILITY TYPE:
740
ADDRESS:1201 BROADWAYTELEPHONE:
(650) 742-9150
CITY:MILLBRAESTATE: CAZIP CODE:
94030
CAPACITY:165CENSUS: 121DATE:
11/08/2024
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Administrator - Joan NewmanTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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- Staff mishandled a resident medication
INVESTIGATION FINDINGS:
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On 11/08/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannonced complaint investigation visit in order to deliver findings regarding the received allegation. LPA met with Joan Newman and explained the purpose of today's visit.

During the investigation, LPA conducted interviews and reviewed pertinent documentation. It was discovered that the facility did not provide a medication to a resident that is prescribed. The medication was stopped being given to the resident without an order on file from the physician. The medication was stopped around February 18, 2024 through April 7, 2024. It was started again after the discovery of it not being given, but then again was stopped around April 27, 2024 thorugh August 17, 2024. The prescription for the medication was not discontinued by the physician at any point. The dosage was decreased per records reviewed, and per interviews, this may have also caused issues with the facility maintaining the medication on their medication records. The medication was not given although it was prescribed by the physician due to facility error. This allegation is substantiated.

Based on LPA interviews and items letters received, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, are being cited on the attached LIC9099D.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2024
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 14-AS-20241007215642
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: CADENCE MILLBRAE
FACILITY NUMBER: 415601039
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/09/2024
Section Cited
CCR
87465(c)(2)
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87465(c)(2) Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This regulation has not been met as evidenced by:
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The facility shall develop a plan of correction addressing how this regulation will be met at all times. Plan of correction to be received by 11/09/2024.
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Based on interviews and documentation reviewed, LPA discovered that the medication was prescribed for the duration of 2024 but was stopped on two spans of time from 2/18/24 through 04/07/24 and 04/27/24 through 08/17/24 without documentation on file from the physician of the resident to discontinue.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2