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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425802105
Report Date: 09/01/2021
Date Signed: 09/01/2021 04:56:26 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
08/27/2021 and conducted by Evaluator Toan Luong
COMPLAINT CONTROL NUMBER: 29-AS-20210827105039
FACILITY NAME:PEOPLE'S CARE LAKE MARIEFACILITY NUMBER:
425802105
ADMINISTRATOR:CHARLOTTE ACOSTA HILLFACILITY TYPE:
735
ADDRESS:2186 LAKE MARIE DRTELEPHONE:
(805) 314-2093
CITY:SANTA MARIASTATE: CAZIP CODE:
93455
CAPACITY:4CENSUS: 4DATE:
09/01/2021
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:House Manager, Lacey HemeonTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff did not provide emergency personnel with an accurate record of resident's medication
Staff did not ensure that resident obtained a prescribed medical test
INVESTIGATION FINDINGS:
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On 9/1/21 at 1:00 PM, LPA Luong conducted an unannounced complaint visit to the People's Care Lake Marie. LPA met with House Manager Lacey Hemeon, explained the purpose of the visit, and toured the facility.
During the investigation, LPA reviewed incident reports received 5/20/21 and Tri-Counties Regional Center Residential Facility Investigation Report and Corrective Action Plan received 8/27/21. Investigation Report outlines on 4/29/21 Client 1 (C1) was prescribed lithium by their physician and was prescribed a blood test to check lithium levels within 7 days of starting the medication. The report indicates based on record review and interviews, between 5/6/21 and 5/20/21 staff attempted to have C1 complete blood draws without success due to C1’s behaviors or C1’s refusal. Staff stated they notified their acting supervisors of the unsuccessful blood draw attempts. On 5/18/21 and 5/20/21, Client 1 (C1) was found on the floor and was lethargic, speaking in a past tense, claimed voices were telling C1 to hurt C1, and threw self on the ground. During both incidents, staff called 9-1-1 and C1 was transported to the emergency room. On both dates, staff provided emergency personnel with an outdated medication record instead of the current record that included lithium.
(Continued on 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Toan Luong
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021
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 3
Control Number 29-AS-20210827105039
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: PEOPLE'S CARE LAKE MARIE
FACILITY NUMBER: 425802105
VISIT DATE: 09/01/2021
NARRATIVE
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(9099 Continued)
The hospital was unaware C1 was taking lithium or that C1’s physician ordered C1’s lithium levels to be checked with a blood test. Facility staff did not ensure emergency medical personnel and hospital personnel had accurate information about C1, including current medications. Facility staff also did not follow physician’s order and ensure C1 had blood work done to ensure C1 had a therapeutic level of the medication and avoid toxicity. C1 was hospitalized on 5/20/21 related to lithium toxicity and acute organ failure. Tri-Counties’ report was received and signed by Administrator Charlotte Acosta Hill on 8/26/21. The above allegation is deemed to be substantiated at this time. Exit interview conducted. Citation issued on 9099-D. Appeal rights emailed. Report emailed to Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Toan Luong
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20210827105039
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: PEOPLE'S CARE LAKE MARIE
FACILITY NUMBER: 425802105
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
09/06/2021
Section Cited
CCR
80075(h)
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80075 Health Related Services
(h) There shall be at least one person capable of and responsible for communicating with emergency personnel in the facility at all times. The requirement is not met as evidenced by:
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Facility will have 2 staff reviews Medication Administration Records to verify current medication list.
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Based on record review, the licensee did not ensure staff provided emergency personnel or hospital personnel C1’s current medication record, which posed an immediate health and safety risk to clients in care.
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Request Denied
Type A
09/06/2021
Section Cited
CCR
85075(b)
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85075 Health-Related Services
(b) The facility shall develop and implement a plan which ensures that assistance is provided to the clients in meeting their medical and dental needs. The requirement is not met as evidenced by:
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Facility will obtain updated physician order if clients refuse medical service.
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Based on record review, the licensee did not ensure C1 had a prescribed medical test, which posed an immediate health and safety risk to clients in care.
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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: Kelly Burley
LICENSING EVALUATOR NAME: Toan Luong
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3