445202878-8-23-2024-26-AS-JJIN-D9W2LJ-20241009172938

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445202878
Report Date: 08/23/2024
Date Signed: 08/23/2024 03:44:00 PM

Unsubstantiated

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
08/08/2024 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20240808094002

FACILITY NAME:	EASTLAKE VILLA HOME CARE		FACILITY NUMBER:	445202878
ADMINISTRATOR:	RECINTO, RACHELLE		FACILITY TYPE:	740
ADDRESS:	591 ARLENE DRIVE		TELEPHONE:	(213) 400-4341
CITY:	WATSONVILLE	STATE: CA	ZIP CODE:	95076
CAPACITY:	10	CENSUS:	DATE:	08/23/2024
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Myla Ilagan		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff did not refill medications timely causing resident to miss medications

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Myla Ilagan. On 08/08/2024, the Department received a complaint with the above allegation. LPA Marrufo conducted an initial complaint investigation visit on 08/15/2024.

During visit on 08/15/2024, LPA observed that resident R1 did not have any medications. Administrator (ADM) Tyrone Vega stated that R1 did not have any medications at the facility because R1’s Medical have been deactivated and thus there were no funds to purchase prescription medication or to pay for a doctor’s visit to prescribe new medications for R1. ADM stated that R1 was admitted to the facility on April 18th, 2024 and R1 had a medication supply that lasted until April 30th, 2024. ADM stated that on May 7th, 2024, ADM received a telephone call from R1’s placement agency and was told that R1’s Medical was de-activated. ADM stated R1’s placement agency did not provide any alternative funding to pay for

See LIC9099-C for more information. Page 1 of 3.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024

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-20240808094002

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: EASTLAKE VILLA HOME CARE	FACILITY NUMBER: 445202878
	VISIT DATE: 08/23/2024

NARRATIVE

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R1’s admission at the facility or for R1’s medications. ADM stated to have made numerous attempted telephone calls to R1’s Family Member (FM) FM1 to seek assistance in re-activating R1’s Medical funding.

LPA reviewed R1’s resident record and obtained copies of resident records. LPA did not observe any documents in R1’s record that R1 is conserved or has a Power-of-Attorney. LPA interviewed R1 during visit and R1 stated that R1 does not need medications.

On 08/16/2024, LPA Marrufo conducted a telephone interview with FM1. FM1 stated to not have any conservatorship or legal authority on behalf of R1. FM1 stated to have visited R1 at the facility and observed changes in R1’s verbal communication that led FM1 to believe R1 was not receiving any medications.

On 08/16/2024, LPA Marrufo conducted a telephone interview with Witness W1, who is a staff at R1’s placement agency. W1 stated that R1 has been R1’s own decision maker throughout the entire process of R1’s Medical becoming de-activated. W1 stated that after R1 was discharged from the hospital before R1 was admitted to the facility, there were discussions within R1’s placement agency that R1 lacked capacity to make decisions and the only person available to help R1 was FM1, who was not R1’s conservator or power of attorney.

On 08/16/2024, LPA Marrufo conducted a telephone interview with Witness W2, who is a staff at R1’s placement agency. W2 stated to have left a voicemail with ADM on 08/02/2024 and then later received a telephone call back from ADM on 08/07/2024 and reported to ADM that R1’s Medical had been re-activated.

See LIC9099-C for more information.

Page 2 of 3.

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20240808094002

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: EASTLAKE VILLA HOME CARE	FACILITY NUMBER: 445202878
	VISIT DATE: 08/23/2024

NARRATIVE

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During interview with ADM on 08/22/2024 at another facility where ADM is a staff and where LPA was conducting an annual inspection visit, ADM stated that R1’s placement agency contacted ADM stating that R1’s Medical had been re-activated. However, ADM stated that when ADM contacted R1’s placement agency’s billing department to receive funds for R1, the billing department staff at R1’s placement agency told ADM that R1’s Medical had not been reactivated and the billing agency would be rejecting ADM’s request for back pay for R1’s care. ADM stated that during a meeting between ADM, R1, and R1’s placement agency that occurred on 08/20/2024, R1 was asked if R1 would like to have R1’s Medical re-activated and R1 declined.

Based on information from interviews conducted with staff, resident, and witnesses, and records reviewed, although the allegation listed above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is unsubstantiated.

No Deficiencies were cited under California Code of Regulations Title 22.

This report was reviewed with Myla Ilagan and a copy of this report was provided.

Page 3 of 3.

END REPORT

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024

LIC9099 (FAS) - (06/04)

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