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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425802106
Report Date: 06/17/2024
Date Signed: 06/20/2024 09:49:00 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
07/11/2023 and conducted by Evaluator Kristin Kontilis
COMPLAINT CONTROL NUMBER: 29-AS-20230711113736
FACILITY NAME:MARIPOSA AT ELLWOOD SHORESFACILITY NUMBER:
425802106
ADMINISTRATOR:MARK CORTESFACILITY TYPE:
740
ADDRESS:190 VIAJERO DRTELEPHONE:
(805) 265-4327
CITY:GOLETASTATE: CAZIP CODE:
93117
CAPACITY:99CENSUS: 69DATE:
06/17/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Sheryl McCaskill, Interim AdministratorTIME COMPLETED:
06:30 PM
ALLEGATION(S):
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Staff are mismanaging resident's medication.
Staff are not ensuring residents medication are refilled timely.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kristin Kontilis conducted a subsequent complaint visit to the facility above to issue final findings. LPA met with Sheryl McCaskill, Interim Administrator and explained the purpose of the visit. During the investigation, LPA Kontilis conducted an initial visit on 7/18/2023 from 11:40 am to 3:30 pm, toured the facility and obtained documents. LPA also conducted a medication audit on 8/9/2023 at 12:35 pm. On 6/13/24, LPA collected additional documents.

On the allegation: Staff are mismanaging resident's medication. On 6/30/2023, R1 stated they had not received their Colchicine for two days. Although Responsible Party 1 (RP1) provided the facility R1’s medication on 6/26/2023, staff could not find the medication and called RP1 twice asking for the refills. RP1 brought up the issue to facility management, who indicated via email they found the Colchicine in their ‘overflow’ area once it was brought to their attention, and addressed the issue with staff.

Please continue to 9099-C, Pg 2.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024
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 8
Control Number 29-AS-20230711113736
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: MARIPOSA AT ELLWOOD SHORES
FACILITY NUMBER: 425802106
VISIT DATE: 06/17/2024
NARRATIVE
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LPA reviewed an email from 7/31/2023 from RP1 to facility management. It states over the weekend, RP1 received a call asking for Colchicine and Miralax for R1. RP1 asked when the medications were needed, and was told R1 was completely out and missed the morning dose. RP1 stated they never received a request to refill the medications prior to running out.
On 8/9/2023 at 12:35 pm, LPA conducted a medication audit of R1’s medications with administrator at the time present. LPA observed the following errors:

· Amlodipine Besylate 5.0mg started 7/18/2023; Med count: 21; should have been 22 count.

· Amlodipine 2.5mg started on 7/29/2023; Med count: 77; should have been 78. Administrator believes the med tech wrote down the wrong start date.

· Aspirin 81mg/day in AM; 500 tablets, started 9/19/2022; 324 days elapsed. Med count: 51; Short 125 tablets.

· Colchicine: 0.6 mg/1 tab/day AM: Started 7/31/2023; 90-day supply; 10 days from 7/31/2023 to 8/9/2023; Med count: 79; Should have 80; count is short one tablet.

· Ezetimibe: 10mg 1/day in AM; started 6/17/2023; 90 tablets; 54 days between 6/172023 & 8/9/2023; Med count is 36 tablets, 2 tablets short.

· 2 orders of Famotidine at 20mg/each order: Started 6/10/2023; 125 tablets to start; 1/day in AM, 1/day at bedtime; 61 days from 6/10/2023 to 8/9/2023; (61 x 2 = 122 tablets/day); Med count: 8 tablets; (On 8/9/2023, one tablet given in AM; bedtime tablet not yet given on 8/9/2023); Med count: 8 tablets; Over 4 tablets.

· Furosemide 40mg: Started 6/1/2023; 1 tab/day in AM; Bottle count: 90 at start; med count: 19 tablets; 1 tablet short.

· Hydralazine 25mg; Qty at start: 270; Start date: 5/31/2023; 1T/2x day at 9 am & 5 pm; 5/31/2023 – 8/9/2023 am: is 71 days; 5/31/2023 – 8/9/2023 pm is 70 days. Total of 141 disbursements; Med count: 130; Should be 129; One tablet over. Administrator stated he believed the start dates were incorrect.

Please continue to 9099-C, Pg 3.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 29-AS-20230711113736
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: MARIPOSA AT ELLWOOD SHORES
FACILITY NUMBER: 425802106
VISIT DATE: 06/17/2024
NARRATIVE
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· Leg cramps (quick dissolve): no mg stated; 1T/bedtime; Start date 6/12/2023: Qty at start: 100; 1T @ bedtime; 58 days from 6/12/2023 to 8/8/2023 (not 8/9/2023 because it is a bedtime med); Med count: 48; four tablets over.

· Levothyroxine 112 mcg: Started on 6/11/2023; 90 qty at start; 29 remaining; 1/day in AM; 59 days from 6/11/2023 – 8/9/2023; Med count: 29 tablets; 12 short.

· Melatonin: 250 count; started 1/16/2023 – 8/8/2023 = 204 days; no mg stated; 1 day/night; OTC; Med count: 46; Accurate.

· Potassium Chloride: 10mek (microtab); Started 5/19/2023; Qty at start: 90; 1/day in AM; 1 remaining in bottle; Short 7 tablets.

· Pravastatin (Sodium): Started 7/16/2023; 40mg; Qty at start: 90; 1/day at bedtime; 7/16/2023 – 8/8/2023 = 24 days; 67 remaining in bottle; 1 extra.

· Methenamine: 1T/day 2x daily at meals (breakfast & dinner); Start date 7/20/2023; Qty at start: 60; 7/20/2023 – 8/9/2023 (AM): 20 days; 7/20/2023 – 8/8/2023 (PM) 19 days; Med count: 19 tablets; Short 2 tablets.

· Metoprolol Tart: 25mg; 1T/2x daily (AM & PM) Start date: 7/5/2023: 7/5/2023– 8/9/2023 = 36 days (AM); 7/5/2023 – 8/8/2023 = 35 days; Qty at start: 180 tablets; Med Count: 110 tablets; 1 over (extra).

LPA observed no records of R1’s medications being refused or destroyed. Per Administrator, an in-service for med techs was held on 8/10/2023.

RP2 stated R2 had eye ointment prescribed for styes 4x per day, including one midnight dose that staff did not provide when resident was sleeping. RP2 asserts that R2 may not have received the ointment as prescribed during the other dosages because the tube was full. LPA was unable to determine whether this ointment was given as prescribed or not given as prescribed. LPA recommends in the future, facility clarify orders that state “X times per day” to ensure resident’s physician agrees with the times the medication is given and if the medications will be given to the residents in the middle of night. The facility should clarify the orders so that residents do not need to be woken up for medications, unless necessary per the physician, and may be less likely to refuse or miss them.

Please continue to 9099-C, Pg 4.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 29-AS-20230711113736
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: MARIPOSA AT ELLWOOD SHORES
FACILITY NUMBER: 425802106
VISIT DATE: 06/17/2024
NARRATIVE
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Based on the information obtained, R1’s medications were not given as prescribed. The facility was already cited for R1’s medication errors on 9/13/2023. A duplicate citation will not be issued but the facility is encouraged to provide staff additional medication training regularly and as-needed to ensure medications are given as prescribed.

On the allegation: Staff are not ensuring residents medication are refilled timely. RP1 stated staff did not notify RP1 in order to get refills timely. LPA observed a screenshot of a text message from Mariposa at Ellwood Shores that shows medication bottles and indicates they need more of this medication, stating “We don’t have none. A soon as possible please [sic].”

RP1 stated in June 2023, they dropped off R1’s refill of Colchicine at the front desk. However, the medication bottle went missing and R1 did not receive the medication for two days as a result. RP1 stated after that incident occurred, they now bring R1’s refills to the medication room or hand them to a med tech. LPA reviewed an email chain that started 6/26/2023, with the facility asking RP1 for 7 of R1’s medications to be refilled. On 7/3/2023, RP1 wrote to facility management that they dropped off all the medications requested on 6/26/2023. Later in the week, med techs called RP1 to ask for the Colchicine medication, which RP1 stated had already been dropped off. On 6/30/2023, RP1 brought the issues to management’s attention verbally. On 6/30/2023, RP1 spoke to a med tech who indicated R1 received the Colchicine, which was confirmed via email on 7/1/2023. Facility management indicated via email they found the Colchicine in their ‘overflow’ area once it was brought to their attention, and addressed the issue with staff, admitting there was an issue.

LPA reviewed an email from 7/31/2023 from RP1 to facility management. It states over the weekend, RP1 received a call asking for Colchicine and Miralax for R1. RP1 asked when the medications were needed and was told R1 was completely out and missed the morning dose. RP1 stated they never received a request to refill the medications prior to running out. Administrator at the time stated they would look into the issue. Based on the information obtained, the allegation is deemed Substantiated at this time.

The following deficiencies were observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in additional civil penalties.



Exit interview conducted. A copy of the report and appeal rights were issued at the time of the visit.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 29-AS-20230711113736
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: MARIPOSA AT ELLWOOD SHORES
FACILITY NUMBER: 425802106
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/19/2024
Section Cited
CCR
87465(a)(2)
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87465(a)(2) Incidental and Medical Care: A plan for incidental medical and dental care shall be developed by each facility. The licensee shall provide assistance in meeting necessary medical and dental needs.

This requirement is not met as evidenced by:
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Administrator agrees to develop a written procedure/plan for staff to ensure refills are obtained timely. Administrator will submit plan to CCL by 6/19/2024.
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Based on record review and interview, the licensee did not comply with the section cited above when not asking for R1’s refills timely, which posed an immediate health and safety risk to residents 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.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 8
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
07/11/2023 and conducted by Evaluator Kristin Kontilis
COMPLAINT CONTROL NUMBER: 29-AS-20230711113736

FACILITY NAME:MARIPOSA AT ELLWOOD SHORESFACILITY NUMBER:
425802106
ADMINISTRATOR:MARK CORTESFACILITY TYPE:
740
ADDRESS:190 VIAJERO DRTELEPHONE:
(805) 265-4327
CITY:GOLETASTATE: CAZIP CODE:
93117
CAPACITY:99CENSUS: 69DATE:
06/17/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Sheryl McCaskill, Interim AdministratorTIME COMPLETED:
06:30 PM
ALLEGATION(S):
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Staff are not ensuring resident's medication record is up-to-date.
Staff are not following doctor's orders.
Facility has not provided residents emergency preparedness training.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kristin Kontilis conducted a subsequent complaint visit to the facility above to issue final findings. LPA met with Sheryl McCaskill, Interim Administrator and explained the purpose of the visit. During the investigation, LPA Kontilis conducted an initial visit on 7/18/2023 from 11:40 am to 3:30 pm, toured the facility and obtained documents. LPA also conducted a medication audit on 8/9/2023 at 12:35 pm. On 6/13/2024, LPA collected additional documents.

On the allegation: Staff are not ensuring resident's medication record is up-to-date. It was alleged R1’s Allopurinol was written incorrectly in the MAR. RP1 stated R1’s Allopurinol 1.5 150 mg was written wrong on the MAR on 7/9/2023, which reduced R1’s dose and their hands swelled as a result. LPA observed R1’s order for Allopurinol changed in April 2023, and the MAR reflects the changes, to 1.5 tablets by mouth

Please continue to 9099-C, Pg 2.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 29-AS-20230711113736
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: MARIPOSA AT ELLWOOD SHORES
FACILITY NUMBER: 425802106
VISIT DATE: 06/17/2024
NARRATIVE
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daily but “facility must verify directions.” LPA observed in July 2023, R1 had changes to their Allopurinol order. From 7/1/2023 to 7/7/2023, R1 took 1.5 tablets (150mg) by mouth daily. Then the order effective 7/8/2023 became two separate orders. One order stated take 1 tablet (no mg) by mouth daily. The MAR indicated 0.5 tabs were given, although the order did not say to give a half tab. The second order stated take 0.5 tablet (50mg) by mouth on Sat, Tues, Thurs for 150mg total. The MAR shows the medication was still given on days that were not Sat, Tues or Thurs (Monday 7/92023, Wednesday 7/12/2023, Friday 7/14/2023). Based on the information obtained, the medication was not given as prescribed, and the facility was already cited for this issue. R1’s MAR was up to date with the changed orders, but it appears it was implemented incorrectly by staff. Therefore, this allegation is deemed Unsubstantiated at this time.
On the allegation: Staff are not following doctor's orders. Since March 2023, R1’s doctor requested staff to check R1’s blood pressure. RP1 stated staff did not fulfill the doctor’s request, so the doctor is unable to prescribe proper medication for R1. LPA observed R1’s Medication Administration Record (MAR) for March 2023 through July 2023. LPA observed March 2023 indicates to check the blood pressure twice per week, and the MAR notes this was completed. April 2023’s MAR shows R1’s blood pressure check changed from twice per week, to three times per day, to once per day, to check daily before and after a medication. The MAR indicates all blood pressure checks were completed for April 2023, May 2023, June 2023, and July 2023 show daily blood pressure checks were given before and after a medication as prescribed. R1’s physician’s orders dated July 2023 state to check R1’s blood pressure in the morning and after a medication dose, and fax the blood pressure records to the physician every Thursday. LPA observed a similar order to take R1’s blood pressure in April 2023 and log it, but the instructions do not say to provide the results to R1’s doctor on a certain basis. LPA was unable to find sufficient information proving the allegation was true and/or occurred. Based on the information obtained, the allegation is deemed Unsubstantiated. The facility is reminded they are responsible for meeting the needs of the residents and must follow all doctor’s orders.
On the allegation: Facility has not provided residents emergency preparedness training. The complainant alleged that the facility did not provide residents with emergency preparedness training. While facility staff are required to have emergency preparedness training and participate in quarterly drills, the regulations do not require residents to participate in the drills, and do not require facilities to allow residents to participate in the drills. A best practice is recommended to the facility to include residents in appropriate emergency

Please continue to 9099-C, Pg 3.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 29-AS-20230711113736
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: MARIPOSA AT ELLWOOD SHORES
FACILITY NUMBER: 425802106
VISIT DATE: 06/17/2024
NARRATIVE
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preparedness training. LPA reviewed facility disaster training held on 4/29/2023, 3/20/2024, 2/21/2024. LPA observed disaster drills covering different shifts completed on 2/28/2023, 4/13/2023, 4/30/2023, 7/31/2023, 9/11/2023, 9/19/2023, 9/20/2023, 9/26/2023, 1/10/2024, 1/15/2024, 1/17/2024, 1/18/2024, 1/30/2024, 3/2/2024, 3/3/2024, 3/4/2024, 3/11/2024, 3/25/2024, 4/10/2024, 4/12/2024, 4/14/2024, 4/30/2024, 5/11/2024, 5/12/2024, 5/15/2024, and 5/22/2024. Based on the information obtained, the allegation is deemed Unsubstantiated at this time.

Exit interview conducted. Copy of report given issued at the time of the visit.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024
LIC9099 (FAS) - (06/04)
Page: 8 of 8