425802106-8-4-2022-29-AS-KBUY-CH5UPU-20220809154607

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425802106
Report Date: 08/04/2022
Date Signed: 08/04/2022 06:44:56 PM

Unsubstantiated

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
06/23/2022 and conducted by Evaluator Jeannette Olson

COMPLAINT CONTROL NUMBER: 29-AS-20220623160311

FACILITY NAME:	MARIPOSA AT ELLWOOD SHORES		FACILITY NUMBER:	425802106
ADMINISTRATOR:	PETER JOHN BONILLA		FACILITY TYPE:	740
ADDRESS:	190 VIAJERO DR		TELEPHONE:	(805) 265-4327
CITY:	GOLETA	STATE: CA	ZIP CODE:	93117
CAPACITY:	99	CENSUS: 80	DATE:	08/04/2022
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Peter Bonilla, Administrator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff mismanaged residents' medication

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA) Olson and Kontilis conducted an unannounced complaint visit to issue final findings. LPA Olson requested relevant documents and interviewed staff on 6/29/22, 7/27/22, 7/29/22, and 8/1/22. LPA Olson interviewed 1 resident on 8/4/22. LPA’s met with Administrator Peter Bonilla and Mark Cortes, Interim Administrator and explained the purpose of the visit.

On the allegation: Staff mismanaged residents' medication. It was alleged that Resident 1 (R1), Resident 2 (R2), and Resident 3 (R3) had fentanyl patches missing, not on their bodies when they should have them on for 3 days (72 hours). LPA Olson interviewed a Manager from Central Coast Hospice which revealed that Central Coast has many patients who live at the facility. The Manager stated there are no concerns with the facility mismanaging medications and fentanyl patches have been known to fall off.

Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022

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-20220623160311

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: 08/04/2022

NARRATIVE

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Hospice notes on 6/5/22 indicated a Temporary Travel Hospice Nurse (H1) went to visit R1 for a Fentanyl patch change and refill, notes indicated R1 did not have a Fentanyl patch on, a caregiver helped assess R1 and both were unable to locate the patch. The nurse placed a new patch on R1’s right upper arm and notified Facility Director. 6/5/22 Resident 2 (R2) Hospice notes state R2 does not have a fentanyl patch on, H1 assessed R2’s skin with caregiver help and both were unable to locate the Fentanyl patch. H1 placed new patch with Tegaderm on upper right arm. H1 informed the Resident Services Director about the missing patch. On 6/2/22 a Fentanyl patch was applied to R2’s left upper arm. The Hospice Manager stated there was not note of a Tegaderm being applied and explained to LPA that Tegaderm is an extra sticky protector usually placed on top of IVs. Hospice notes for Resident 3 (R3) from 5/29/22 indicate that the Fentanyl patch was not found on R3, a new patch was applied and Resident Services Director was notified.

LPA interviewed Resident Services Director who stated they were aware of R2 and R3 missing a patch but not R1. The Resident Services Director called the primary Hospice Nurse (H2) regarding the missing patches the following day who said that patches fall off all the time, and to not worry about it. LPA interviewed Hospice Nurse (H2) who stated that their patient R3 has lost their Fentanyl patch twice but it had always been found. On 6/1/22 during the visit with R3 the missing patch was found on R3’s arm and two patches were present. The other time it was lost a few months ago H2 found it in the laundry. H2 explained that they have been working at the facility as a Hospice Nurse for over 3 years and believes there is no dispersion whatsoever. H2 explained that fentanyl patches fall off “all the time”, they are sticky and will stick to sheets and blankets which end up in the laundry.

LPA Olson interviewed a medtech who stated that they present with the Hospice Nurse (H1) during a visit with R3. The medtech witnessed no patch on R3 and states that they looked everywhere for it. The medtech could not recall what date this occurred but remembers the Hospice Nurse stating that it might have fallen off so they applied a Tegaderm on top of the Fentanyl patch to protect it.

LPA Olson was not able to interview Resident 1 because they had passed away on 7/21/22. Resident 2 was unable to be interviewed because they were non verbal. LPA interviewed Resident 3 who stated that their pain was managed well. R3 was not sure if they had fentanyl patches but they do remember something being on their arm. R3 does not remember if it ever fell off. LPA requested R3s MAR which shows R3 Fentanyl patch was discontinued on 6/8/22. Based on interviews and record review the allegation is deemed unsubstantiated at this time. Exit interview conducted. Report issued via email to Administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022

LIC9099 (FAS) - (06/04)

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