435202414-11-30-2020-26-AS-KHOS-BVWT2C-20201202132027

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202414
Report Date: 11/30/2020
Date Signed: 11/30/2020 03:09:31 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
07/08/2020 and conducted by Evaluator Gladys Kuizon

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20200708152707

FACILITY NAME:	DURALIZA CARE HOME		FACILITY NUMBER:	435202414
ADMINISTRATOR:	AIDA D. PENDON		FACILITY TYPE:	740
ADDRESS:	1938 ENSIGN WAY		TELEPHONE:	(408) 923-1160
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95133
CAPACITY:	6	CENSUS: 6	DATE:	11/30/2020
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Aida Pendon & Rhonald Aranzaso		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility did not dispense medication as prescribed.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Gladys Kuizon conducted a subsequent complaint tele-visit today to deliver investigation findings. Due to COVID-19 preventive measures, facility visits have been suspended. LPA met with Administrator Aida Pendon and Rhonald Aranzaso.

On July 8, 2020, the Department received the above allegations against this facility. Reporting party (RP) alleged that resident (R1) was being neglected by facility staff. LPA interviewed RP on July 9, 2020.

On July 14, 2020, LPA conducted an unannounced initial complaint investigation tele-visit and interviewed facility administrator (ADM). Facility records were requested.

Continued, see LIC 9099-C, page 2 of 2.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys Kuizon	TELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2020

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-20200708152707

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: DURALIZA CARE HOME	FACILITY NUMBER: 435202414
	VISIT DATE: 11/30/2020

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

From July 9, 2020 to August 11, 2020, LPA conducted interviews. LPA interviewed 6 staff members and met with 6 residents.

Due to developmental disabilities, LPA was unable to obtain relevant responses from 4 out of 6 residents. Resident, R1, stated that staff does not give R1's Ibuprofen when R1 requests it and staff does not buy R1's medicated powder, Gold Bond. Resident, R2, has no knowledge regarding R1's medications.

LPA reviewed R1's medication administration record (MAR) and medication list. Based on R1's medication list dated July 6, 2020, Ibuprofen and Gold Bond (medicated powder) were not prescribed by R1's physician and staff is following physician's orders by not providing it to R1 upon request.

Based on interviews, 6 out of 6 staff members stated that R1 is being assisted by staff with medications. Staff, S2, confirmed being responsible for ordering residents' medications refills and recording medications administration. During interview on August 24, 2020, S2 stated that on June 25, 2020, R1 ran out of one inhaler prescribed to be used 4 times daily. S2 stated that upon review, R1 ran out of refills for this inhaler and R1's physician would not order a refill until R1 is seen by physician. A doctor's appointment was scheduled on June 26, 2020 and R1's physician ordered the refill and sent the order directly to the pharmacy to be filled and mailed. As of July 1, 2020, S2 followed up with the pharmacy because the inhaler was still not received. S2 was informed that there was no order received by the pharmacy due to a lapse in communication between the doctor's office and the pharmacy.

On July 2, 2020, the inhaler was picked up by facility staff. R1 was not administered the inhaler as prescribed from June 26, 2020 to July 2, 2020.

Based on records reviewed and interviews conducted, the facility did not request resident's medication refill prior to resident running out of medication causing resident to miss multiple dosages of said medication.

The Department has conducted an investigation of the above allegation. Based on interviews and records reviewed, the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED.

A deficiency was cited today. See LIC 9099-D.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys Kuizon	TELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20200708152707

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: DURALIZA CARE HOME	FACILITY NUMBER: 435202414
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/30/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/01/2020 Section Cited CCR 87465(c)(2)	1 2 3 4 5 6 7	87465 INCIDENTAL MEDICAL AND DENTAL CARE (c)(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Facility to develop a written plan of action and submit to CCLD by POC due date.
	8 9 10 11 12 13 14	Based on records reviewed and staff interview, R1 was not given daily doses of prescribed inhaler from 06/26/2020 to 07/02/2020 due to medication refill not being ordered timely by facility staff. This posed an immediate risk to the health of R1.	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: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys Kuizon	TELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2020

LIC9099 (FAS) - (06/04)

Page: 3 of 3