045002773-3-19-2024-59-AS-KHOS-D3XPMR-20240402112645

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 045002773
Report Date: 03/19/2024
Date Signed: 03/19/2024 10:06:05 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/27/2024 and conducted by Evaluator Rebecca Knight

COMPLAINT CONTROL NUMBER: 59-AS-20240227084128

FACILITY NAME:	ROSELEAF OROVILLE		FACILITY NUMBER:	045002773
ADMINISTRATOR:	BINGHAM, DIANIA		FACILITY TYPE:	740
ADDRESS:	1900 20TH ST		TELEPHONE:	(530) 538-8200
CITY:	OROVILLE	STATE: CA	ZIP CODE:	95965
CAPACITY:	60	CENSUS: 36	DATE:	03/19/2024
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Stacey Baxter - Administrator		TIME COMPLETED:	10:15 AM

ALLEGATION(S):

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Staff mismanaged medication resulting in resident to be hospitalized - SUBSTANTIATED

INVESTIGATION FINDINGS:

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03/19/2024 10:00 AM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with administrator Stacey Baxter. The purpose of this visit was to deliver the results of a complaint investigation.

During the course of the investigation LPA interviewed the COO and 1 med tech.

Continued on LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20240227084128

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ROSELEAF OROVILLE	FACILITY NUMBER: 045002773
	VISIT DATE: 03/19/2024

NARRATIVE

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Staff mismanaged medication resulting in resident to be hospitalized - SUBSTANTIATED

LPA reviewed an incident report that was submitted on 02/27/2024 regarding an incident that occurred on 02/22/2024. It was reported that at 8:00 pm a Medication Technician, Staff 1 (S1) reported that they gave another resident's medication to Resident 1 (R1) who was admitted to the facility that same day. EMS was called. EMS arrived, stated that R1’s vital signs were stable and R1 was transported to ER for evaluation. R1 was subsequently hospitalized for observation. No adverse effects were reported as a result of the medication error. R1 returned to community on 02/24/2024.

During the course of the investigation, it was learned that when R1 was admitted to the facility their admission record did not include R1’s photograph for identification. S1 failed to follow the facility’s medication safety checks which include confirmation of resident by matching the photograph on file with the resident they are dispensing the medication to.

Staff 1 stated that verifying a resident’s photograph (identifying the right person) that a medication is being dispensed is part of the “Six Rights” that the facility uses for dispensing medications.

It was determined that even though there was no photograph in the resident’s file, S1 should not have dispensed the medication to R1 without confirming they were dispensing to the correct resident. This allegation is substantiated.

Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview conducted and a copy of the report was provided to administrator Stacey Baxter.

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20240227084128

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ROSELEAF OROVILLE	FACILITY NUMBER: 045002773
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/19/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/02/2024 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465(a)(4) Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee agrees to conduct a medication distribution training for all staff and will provide LPA with training subject matter and sign in sheet with dates and staff signatures.
	8 9 10 11 12 13 14	Based on interviews and document review it was determined that a med tech dispensed the wrong medication to 1 resident resulting in hospitalization. This poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	The proof of correction is to be received by LPA Knight by 04/02/2024.
	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: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024

LIC9099 (FAS) - (06/04)

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