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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425850025
Report Date: 11/16/2021
Date Signed: 11/16/2021 01:46:27 PM



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
08/28/2020 and conducted by Evaluator Arien Diaz
COMPLAINT CONTROL NUMBER: 29-AS-20200828153423
FACILITY NAME:SANTA MARIA TERRACEFACILITY NUMBER:
425850025
ADMINISTRATOR:ENRIQUEZ, SANJUANAFACILITY TYPE:
740
ADDRESS:1405 E MAIN STTELEPHONE:
(805) 925-8713
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY:140CENSUS: 83DATE:
11/16/2021
UNANNOUNCEDTIME BEGAN:
12:50 AM
MET WITH:Vanessa VazquezTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Staff did not ensure resident received insulin.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Diaz conducted a complaint visit to deliver final findings of the complaint investigation conducted by LPA Diaz.

LPA Diaz reviewed facility documents and conducted interviews with staff and residents. LPA interviewed staff on 09/03/20 at 11:50am,12:30pm and interviewed staff on 7/27/21 at 6:30pm. LPA interviewed staff on 08/04/21 at 3:45pm, 6:00pm at 6:35pm. LPA interviewed staff on 08/05/21 at 3:30pm, 5:30pm 5:46pm 6:51pm. LPA interviewed clients on 08/05/21 at 5:54pm and at 6:03pm. LPA interviewed clients on 08/06/21 at 10:36am, 10:48am, 11:01am, 11:10am, 11:16am, 11:23am and on 08/09/21 at 4:00pm. On the allegation: Staff did not ensure resident received insulin: LPA interviewed residents that are on the medication program at the facility, and 9 out of 9 residents stated that they receive their medications without any issues. 9 out of 9 residents stated MedTech’s are good at providing medication on time or when needed. 3 out of 9 residents stated the facility administers medication on time or within the permitted time window.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Arien DiazTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
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 5
Control Number 29-AS-20200828153423
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: 11/16/2021
NARRATIVE
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All staff stated that MedTech’s document the medications administered in the medication log. The MedTech’s review the MAR and discuss administered medication, new medication, change of behavior, resident refusing medication, and any resident concerns. 9 out of 9 staff stated there is good communication between MedTech’s during shit changes and as a result very few medication errors occur. Staff 1 (S1) stated, Resident 1 (R1) had left the facility but returned during the night a few days later. Due to lack of communication, the morning MedTech was unaware that R1 returned to the facility and therefore did not provide R1 with their insulin. Later that day, S1 was working in the afternoon and R1 told S1 that they did not receive their insulin in the morning. S1 checked R1 and blood sugar was normal. Since this incident, the facility created a MedTech log that indicates medication administered and the status regarding the resident’s whereabouts. Based on the interviews and observations, the allegation Staff did not ensure resident received insulin is deemed substantiated at this time.

Exit interview, deficiency cited on 9099-D, report given, appeal rights given.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Arien DiazTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20200828153423
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: 11/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/16/2021
Section Cited
CCR
87465(c)(2)
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87465(c)(2) Incidental Medical and Dental Care. Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced By:
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Licensee agreed to submit a plan to licensing about their new medication, status and communication procedures. Plan will be submitted by 11/19/2021 to LPA by email (arien.diaz@dss.ca.gov)
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Based on medication review, the licensee failed to ensure medications were not given as prescribed for resident 1. (R1) which poses 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: Arien DiazTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
LIC9099 (FAS) - (06/04)
Page: 3 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
08/28/2020 and conducted by Evaluator Arien Diaz
COMPLAINT CONTROL NUMBER: 29-AS-20200828153423

FACILITY NAME:SANTA MARIA TERRACEFACILITY NUMBER:
425850025
ADMINISTRATOR:ENRIQUEZ, SANJUANAFACILITY TYPE:
740
ADDRESS:1405 E MAIN STTELEPHONE:
(805) 925-8713
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY:140CENSUS: 83DATE:
11/16/2021
UNANNOUNCEDTIME BEGAN:
12:50 AM
MET WITH:Vanessa VazquezTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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2
3
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5
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9
Staff did not provide resident adequate food service.
INVESTIGATION FINDINGS:
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5
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Licensing Program Analyst (LPA) Diaz conducted a complaint visit to deliver final findings of the complaint investigation conducted by LPA Diaz. LPA Diaz reviewed facility documents and conducted interviews with staff and residents. LPA interviewed staff on 09/03/20 at 11:50am,12:30pm and interviewed staff on 7/27/21 at 6:30pm. LPA interviewed staff on 08/04/21 at 3:45pm, 6:00pm at 6:35pm. LPA interviewed staff on 08/05/21 at 3:30pm, 5:30pm 5:46pm 6:51pm. LPA interviewed clients on 08/05/21 at 5:54pm and at 6:03pm. LPA interviewed clients on 08/06/21 at 10:36am, 10:48am, 11:01am, 11:10am, 11:16am, 11:23am and on 08/09/21 at 4:00pm.

On the allegation: Staff did not provide resident adequate food service: 9 out of 9 residents stated they like the staff and they like living in the facility. All residents stated the food is generally good and there is plenty of food in the facility to feed the residents. 9 out of 9 residents stated the facility serves a substantial amount of food and residents are entitled to request more food if they are still hungry. Residents also have the option to request alternative meals and the staff also escort residents to the dining hall.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Arien DiazTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20200828153423
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: 11/16/2021
NARRATIVE
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All staff stated that the facility serves plenty of good quality food and residents are escorted to the dining hall or food is delivered by staff. According to the administrator, breakfast, lunch and dinner were served to the resident’s room during part of the COVID-19 pandemic. There are two server’s that deliver food and beverages to the rooms. The kitchen has checklist/log to indicate when meals are made, and when meals are delivered. The meals are served one floor at a time to ensure that meals are served hot. LPA observed a dinner plate being prepared in the kitchen, and the plate was of substantial size and of good quality. LPA observed fresh fruits vegetables and a variety of meats inside the kitchen freezer. Based on the interviews and observations, the allegation Staff did not provide resident adequate food service is deemed unsubstantiated at this time.

Exit interview, report given.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Arien DiazTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5