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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 455002480
Report Date: 08/20/2024
Date Signed: 08/20/2024 09:29:11 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
06/04/2024 and conducted by Evaluator Ivan Avila
COMPLAINT CONTROL NUMBER: 59-AS-20240604155955
FACILITY NAME:NEW VISION SERVICES, INC. 1FACILITY NUMBER:
455002480
ADMINISTRATOR:WATKINS, AMBERFACILITY TYPE:
735
ADDRESS:752 ESTATE STREETTELEPHONE:
(530) 222-1681
CITY:REDDINGSTATE: CAZIP CODE:
96002
CAPACITY:6CENSUS: 3DATE:
08/20/2024
UNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Evelyn WilliamsTIME COMPLETED:
09:45 AM
ALLEGATION(S):
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Staff dispensed wrong medication
INVESTIGATION FINDINGS:
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On 08/20/2024 Licensing Program Analyst (LPA) Ivan Avila conducted an unannounced complaint investigation visit regarding the above allegation directed by the Department. LPA met with Evelyn Williams and explained the purpose of the visit.

During the investigation process, interviews and a records review were initiated.

LPA investigated the allegation, “Staff dispensed wrong medication.” LPA interviewed the Administrator, and it was reported that C1 was given C2s medication in error. C1 and C2 share the same first same and staff did not follow facility policy on medication procedures.

Continued on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Ivan Avila
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024
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 59-AS-20240604155955
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: NEW VISION SERVICES, INC. 1
FACILITY NUMBER: 455002480
VISIT DATE: 08/20/2024
NARRATIVE
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LPA reviewed the incident report submitted to the department by the facility which lists the medication errors given to C1. C1 was taken to the hospital for observation.

Based on LPAs observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, and the California Health and Safety Code are cited on the attached LIC9099-D.

An exit interview was conducted, and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Ivan Avila
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20240604155955
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: NEW VISION SERVICES, INC. 1
FACILITY NUMBER: 455002480
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/20/2024
Section Cited
CCR
80075(b)
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80075(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement is not met as evidence by:
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Licensee and staff will complete a medication administration training. Licensee will email proof of completed training with all staff signatures to LPA by POC due date 08/23/2024.
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Based on interview and record review, the licensee did not comply with the section cited above as client received the wrong medication, which possesses an immediate Health, Safety, and Personal Rights risk to persons in care.
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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: Anthony Perez
LICENSING EVALUATOR NAME: Ivan Avila
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3