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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 430707097
Report Date: 10/16/2024
Date Signed: 10/16/2024 01:43:02 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/22/2024 and conducted by Evaluator Manuel Monter
COMPLAINT CONTROL NUMBER: 26-AS-20240222110145

FACILITY NAME:PARK AVENUE ADULT RESIDENTIAL FACILITIESFACILITY NUMBER:
430707097
ADMINISTRATOR:EUSTAQUIO,CECILIAFACILITY TYPE:
735
ADDRESS:1992 & 1998 PARK AVENUETELEPHONE:
(408) 241-0605
CITY:SAN JOSESTATE: CAZIP CODE:
95126
CAPACITY:12CENSUS: 8DATE:
10/16/2024
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator, Cecilia EustaquioTIME COMPLETED:
01:50 PM
ALLEGATION(S):
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Facility is not administering Residents medications per physicians orders
INVESTIGATION FINDINGS:
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On February 22, 2024, the department received a complaint alleging the facility is not administering residents’ medications per physician’s orders.

On February 29, 2024, Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced complaint investigation visit.

Licensing Program Analyst Manuel Monter randomly audited/reviewed 3 residents’ medications (R1, R6 & R7). LPA requested the residents Medication Administration Record (MAR) and Centrally Stored Medication record. LPA also requested R1, R6, R7’s medication bottles/containers to cross reference the medication with the MAR and Centrally Stored Medication log. Staff S1 counted the medication tablets for LPA.

Page 1 Out of 2.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
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 26-AS-20240222110145
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: PARK AVENUE ADULT RESIDENTIAL FACILITIES
FACILITY NUMBER: 430707097
VISIT DATE: 10/16/2024
NARRATIVE
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While reviewing Resident R1’s medications, a discrepancy was discovered. R1’s Medication 1 had an excess of 11 tablets. R1’s medication 1 bottle had the following information: Take tablet by mouth twice a day.

LPA reviewed resident R6’s medications. While auditing R6’s medications, LPA discovered that medication 1 had an excess of 13 tablets and Medication 2 had an excess of 3 tablets. R6’s medication 1 bottle had the following information: 1 tablet for bedtime. R6’s medication 2 bottle had the following information: 1 tablet for bedtime.

LPA reviewed resident R7’s medications. While auditing R7’s medications, LPA discovered that medication 1 had was short 4 tablets and Medication 2 had an excess of 24 tablets. R7’s medication 1 bottle had the following information: Place 2 tablets by mouth and allow to dissolve at bedtime. R7’s medication 2 bottle had the following information: take 3 tablets by mouth at bedtime.


LPA interviewed ADM. ADM stated the residents R1, R6 & R7 don’t refuse their medication. ADM stated she does not have a copy of R1, R6 & R7’s Medication Administration Record. ADM stated she doesn’t know why there a discrepancy in the pill count.

On March 5, 2024, LPA Manuel Monter interviewed Administrative Assistant, (AA).
AA stated some residents do refuse to take their medications sometimes.

Based on interviews and observation/inspection of the facility, the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED.

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 9099-D. This report was reviewed with Administrator, Cecilia Eustaquio and a copy of the report was provided. Appeal Rights was provided.

Page 2 Out of 2. END OF REPORT.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 26-AS-20240222110145
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: PARK AVENUE ADULT RESIDENTIAL FACILITIES
FACILITY NUMBER: 430707097
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/17/2024
Section Cited
CCR
80075(b)
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 80075 Health Related Services (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement was not met as evidenced by;
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ADM stated she will send a written plan of action on how she will ensure residents physician’s orders regarding medication administration is followed.
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Based on medication audit, R1, R6 and R7’s medications had either instances of excess and deficit of medication tablets. R1, R6 and R7 cannot administer their own medication. This poses/posed an immediate health, safety or personal rights risk to persons in care.
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ADM stated she will send the written plan of action by POC date, October 17, 2024.
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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: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5