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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 430707868
Report Date: 04/28/2023
Date Signed: 04/28/2023 03:59:09 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
04/20/2023 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20230420121839
FACILITY NAME:FLORENCE RESIDENTIAL CARE HOME #2FACILITY NUMBER:
430707868
ADMINISTRATOR:PERLA DIMALANTA ZEIJNALIFACILITY TYPE:
735
ADDRESS:135 NORTH 8TH STREETTELEPHONE:
(408) 293-0362
CITY:SAN JOSESTATE: CAZIP CODE:
95112
CAPACITY:10CENSUS: 9DATE:
04/28/2023
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Winniw RodriguezTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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9
Staff do not dispense medications as prescribed.
Staff do not keep accurate records of medications.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with staff Winnie Rodriguez.

LPA Marrufo conducted an initial complaint investigation visit on 04/24/2023. During today's visit, LPA Marrufo reviewed medications and medication records for residents R1-R9. LPA Marrufo interviewed 7 out of 9 residents and attempted an interview with an additional resident who refused to be interviewed. LPA Marrufo interviewed staff S1. LPA Marrufo interviewed Administrator Perla Zeijnali over telephone during visit.

7 out of 7 interviewed residents stated that they receive medications according to prescription. staff S1 stated to provide medications accoridng to prescription.

See LIC9099-C for more information. Page 1 of 2.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023
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 3
Control Number 26-AS-20230420121839
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: FLORENCE RESIDENTIAL CARE HOME #2
FACILITY NUMBER: 430707868
VISIT DATE: 04/28/2023
NARRATIVE
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During review of medications and medication records for residents R1-R9, LPA Marrufo made the following observations. R2 had 3 unopened boxes of medications with the seal left unbroken on the box lid. R8 had a medication in a bubble pack with pills for days 1 through 12 still in the bubble pack, while R8's Medication Administration Record (MAR) had initials on every day of the month of April for days 1-27. R9 had a bedtime medication in a bubble pack with the pills for days 1-5 still in the bubble pack. The bubble pack for the morning version of the medication had pills in the bubbles for days 1-4 and 11-30. The fill date for both medications was 03/06/2023 and the March MAR stated that the medications were given for days 1-31 of March. R9 also had a bubble pack for a medication with a quantity of 15 that is supposed to be given every other day. The fill date for the medication was 03/13/2023. The bubble pack still had pills for days 25, 27, and 29. The March MAR had initials for 15 days of the medication.

Residents R3, R6, and R7 did not have a current Centrally Stored Medication Log (CSML). R9 had a medication that was not entered into R9's CSML.

During visit, LPA Marrufo provided a copy of the Medications Guide for Adult Residential Facilities to facility staff.

Based on records review, interviews and observations there is preponderance of evidence to prove the alleged violations did occur. Therefore, the allegations are substantiated.

See 9099-D for deficiencies cited per the California Code of Regulations, Title 22.

This report was reviewed with staff Winnie Rodriguez and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 26-AS-20230420121839
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: FLORENCE RESIDENTIAL CARE HOME #2
FACILITY NUMBER: 430707868
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/29/2023
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: Licensee did not ensure that 3 out of 9 residents did not have medications in their
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Licensee agrees to submit a plan of correction by POC date to train staff on assisting residents with the administration of prescription and non-prescription medications. Once staff are trained, Licensee agrees to submit records of training, including names of staff trained, training dates, topic
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medication containers that should have been provided to residents, which poses an immediate safety risk to residents in care.
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of training, and name and qualifications of trainer.
Type B
05/05/2023
Section Cited
CCR
80075(k)(7)(A)-(H)
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80075 Health Related Services (k) The following requirements shall apply to medications which are centrally stored: (7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least
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Licensee agrees to conduct an in-service training by POC date on how to ensure the maintenaince of a record of centrally stored prescription medications for each client. Once staff are trained, Licensee agrees to submit records of training, including names of staff trained, training dates, topic
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one year and includes the following: (A) The name of the client for whom prescribed. (B) The name of the prescribing physician. (C) The drug name, strength and quantity. (D) The date filled. (E) The prescription number and the name of the issuing pharmacy. (F) Expiration date. (G) Number of refills. (H) Instructions, if any, regarding control and custody of the medication.

This requirement was not met as evidenced by: Licensee did not ensure that 3 out of 9 residents had current Centrally Stored Medication Logs and 1 out of 9 residents had each medication entered into the Centrally Stored Medication Log, which poses a potential safety risk to residents in care.
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of training, and name and qualifications of trainer.
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: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3