425850025-6-15-2023-29-AS-KBUY-CT7QHW-20230627121149

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425850025
Report Date: 06/15/2023
Date Signed: 06/15/2023 11:06:55 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
02/24/2023 and conducted by Evaluator Jeannette Olson

COMPLAINT CONTROL NUMBER: 29-AS-20230224144738

FACILITY NAME:	SANTA MARIA TERRACE		FACILITY NUMBER:	425850025
ADMINISTRATOR:	ENRIQUEZ, SANJUANA		FACILITY TYPE:	740
ADDRESS:	1405 E MAIN ST		TELEPHONE:	(805) 925-8713
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93454
CAPACITY:	140	CENSUS: 94	DATE:	06/15/2023
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Joanna Enriquez, Administrator		TIME COMPLETED:	11:20 AM

ALLEGATION(S):

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Staff did not provide complete records to authorize representative.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Olson conducted an unannounced subsequent complaint visit to issue final findings on the allegation above. LPA interviewed reporting party on 3/1/23, interviewed Administrator and Care Staff on 3/2/23 and 6/12/23 and and requested relevant documents, and Wellness Director on 5/30/23. LPA met with Administrator and explained the purpose of the visit.

On the allegation: Staff did not provide complete records to authorize representative. It was alleged that R1’s responsible parties requested records multiple times with no response. Interviews revealed the responsible party wanted records of the time medication was given and a staff agreed to check with IT to see how to print that information and would get back to them. At the time of the visit the staff said it still wasn’t provided. Interviews also revealed that the MAR and other documents wouldn’t print when the responsible party requested it. Staff wasn’t sure if it had been given but agreed to check. Based on the information obtained, the responsible party still hadn’t received records requested as of mid April, therefore the allegation is deemed Substantiated at this time. Exit interview conducted, copy of report and appeal rights were printed.

Substantiated

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: 06/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023

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 5

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
02/24/2023 and conducted by Evaluator Jeannette Olson

COMPLAINT CONTROL NUMBER: 29-AS-20230224144738

FACILITY NAME:	SANTA MARIA TERRACE		FACILITY NUMBER:	425850025
ADMINISTRATOR:	ENRIQUEZ, SANJUANA		FACILITY TYPE:	740
ADDRESS:	1405 E MAIN ST		TELEPHONE:	(805) 925-8713
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93454
CAPACITY:	140	CENSUS:	DATE:	06/15/2023
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:			TIME COMPLETED:	11:20 AM

ALLEGATION(S):

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Facility staff dispensed wrong medications to resident in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Olson conducted an unannounced subsequent complaint visit to issue final findings on the allegations above. LPA interviewed reporting party on 3/1/23, interviewed Administrator and Care Staff on 3/2/23 and 6/12/23 and requested relevant documents, and Wellness Director on 5/30/23. LPA met with Administrator and explained the purpose of the visit.

On the allegation: Facility staff dispensed wrong medications to resident in care. It was alleged that Resident 1 (R1) was given 8 Excedrin Migraine pills instead of the prescribed 8 Acetaminophen tablets. Resident 1 was admitted to the facility as respite on 1/30/23 and left the facility on 2/19/23. On 2/22/23 R1 was hospitalized for a GI bleed.

LPA Olson reviewed R1’s MAR with Excedrin Migraine Oral Tablet 250 MG “Give 2 tablet by mouth one time a day for headache.” Acetaminophen Extra Strength Oral Tablet 500 MG “Give 2 tablet by mouth three times a day for pain relief” (starting 2/10/23). 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: 06/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 29-AS-20230224144738

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: SANTA MARIA TERRACE	FACILITY NUMBER: 425850025
	VISIT DATE: 06/15/2023

NARRATIVE

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LPA was provided pictures of the Excedrin Migraine bottle provided to the facility. There was one Kirkland “Migraine Headache Relief” Bottle (250mg Acetaminophen, 250mg Aspirin, 65mg Caffeine), 400 count with a lid that has “NOC” written and “noon” “evening” and “bedtime” stickers. There is another sticker that says “Directions: 2 tab po 4 times a day” on that bottle. There was also an Excedrin Migraine bottle with a “morning” sticker on the lid. The reporting party stated no Acetaminophen bottle was returned to R1 when they moved out of the facility.

Reporting party stated they feel R1 was given the Kirkland Migraine Headache Relief instead of Acetaminophen. The Kirkland Migraine Headache Relief has Acetaminophen in it, and it was possibly given 4 times a day as the Acetaminophen, in addition to the 2 tabs of Excedrin Migraine. LPA visited the facility on 3/2/23 and observed there to be leftover medication for Resident 1 that was not picked up, including a Kirkland Acetaminophen Extra Strength 500 count bottle.

LPA interviewed MedTech’s who said it was possible that the Kirkland Migraine Headache Relief was given instead of the Acetaminophen, because the bottles look almost identical and both have acetaminophen as the first ingregient. When LPA interviewed the MedTechs, LPA showed them pictures of the two bottles (Acetaminophen and Kirkland Migraine Headache Relief) and asked which medication they would give for Acetaminophen. Only one MedTech indicated they would give the Kirkland Migraine Headache Relief, then later stated they were only 50% sure, while the rest of the MedTechs stated they were not sure. Wellness Director stated that while it is very possible the bottles were mixed up because they both have Acetaminophen as the first ingredient, there is a 7 step process that Medtechs go through to ensure the right medication is being given. Wellness Director stated for example, the process is for the Medtech to pull out all bottles that had “morning” on them that would have included the Excedrin Migraine, Kirkland Migraine Headache Relief, and Kirkland Acetaminophen and go through each order for the morning to make sure the correct medication is dispensed. However, they could see the possibility of them dispensing the Migraine Headache Relief as Acetaminophen because they look so similar and appear to match.

LPA interviewed the family who stated they can’t remember if they gave the facility a brand new bottle of any medications or if some were opened. LPA reviewed the Centrally Stored Medication and Destruction Record, which indicated the quantity were full bottles, but the Medtech’s interviewed stated they didn’t know they had to count the medications received if the bottles were open. This will be addressed in a Case Management visit. Continued on 9099-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5

Control Number 29-AS-20230224144738

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: SANTA MARIA TERRACE	FACILITY NUMBER: 425850025
	VISIT DATE: 06/15/2023

NARRATIVE

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Based on the information obtained, there is not enough evidence to prove an incorrect medication was given, therefore the allegation is deemed Unsubstantiated at this time. LPA recommends the facility provide additional medication training to MedTechs to ensure they fully read the bottle of medication, instead of relying on how the bottle looks or on stickers.
Exit interview conducted, copy of the report was printed and emailed.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 29-AS-20230224144738

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: SANTA MARIA TERRACE	FACILITY NUMBER: 425850025
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/15/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/22/2023 Section Cited CCR 87506(c)(1)	1 2 3 4 5 6 7	87506(c)(1) The licensee shall be responsible for storing active and inactive records...The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative. This requirement was not	1 2 3 4 5 6 7	Administrator agreed to submit a statement of understanding of regulation 87506 and will make a plan on how to follow up on record requests in a timely manner and submit to CCL by 6/22/23.
	8 9 10 11 12 13 14	met as evidenced by: Based on interviews, the licensee did not comply with the section cited above when the facility did not make records available to the resident or representative, which poses a potential health, safety or personal rights risk to persons 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: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5