455002550-6-16-2022-25-AS-MSEY-CFSKZC-20220627082032

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 455002550
Report Date: 06/16/2022
Date Signed: 06/16/2022 06:07:29 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/13/2022 and conducted by Evaluator Misty Valencia

COMPLAINT CONTROL NUMBER: 25-AS-20220613133523

FACILITY NAME:	SERENITY GARDENS		FACILITY NUMBER:	455002550
ADMINISTRATOR:	CAIN, BETTY		FACILITY TYPE:	740
ADDRESS:	1233 WILLIS STREET		TELEPHONE:	(530) 605-4033
CITY:	REDDING	STATE: CA	ZIP CODE:	96001
CAPACITY:	30	CENSUS: 25	DATE:	06/16/2022
		UNANNOUNCED	TIME BEGAN:	11:55 AM
MET WITH:	Betty Cain, Administrator		TIME COMPLETED:	01:50 PM

ALLEGATION(S):

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Staff dispensed the wrong medication to a resident in care

INVESTIGATION FINDINGS:

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On 06/16/2022, Licensing Program Analyst (LPA) Misty Valencia conducted an unannounced complaint investigation visit regarding the above allegation directed by the department. LPA met with Betty Cain, Administrator, and explained the reason for the visit. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted Administrator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical masks. Additionally, LPA was screened by staff at the front door.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Misty Valencia	TELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/13/2022 and conducted by Evaluator Misty Valencia

COMPLAINT CONTROL NUMBER: 25-AS-20220613133523

FACILITY NAME:	SERENITY GARDENS		FACILITY NUMBER:	455002550
ADMINISTRATOR:	CAIN, BETTY		FACILITY TYPE:	740
ADDRESS:	1233 WILLIS STREET		TELEPHONE:	(530) 605-4033
CITY:	REDDING	STATE: CA	ZIP CODE:	96001
CAPACITY:	30	CENSUS:	DATE:	06/16/2022
		UNANNOUNCED	TIME BEGAN:	11:55 AM
MET WITH:			TIME COMPLETED:	01:50 PM

ALLEGATION(S):

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Staff did not provide related incident documents to a resident's representative.

INVESTIGATION FINDINGS:

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Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Misty Valencia	TELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2022

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

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 25-AS-20220613133523

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: SERENITY GARDENS	FACILITY NUMBER: 455002550
	VISIT DATE: 06/16/2022

NARRATIVE

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Staff did not provide related incident documents to a resident's representative.

The department investigated the allegation of Staff did not provide related incident documents to a resident's representative. The department conducted interviews and reviewed records concerning the allegation. Through interviews it was determined that staff did contact responsible party (RP) after hours on a Saturday 6/11/22, then Monday 6/13/22 the RP called back to confirm that RP did receive the incident report as well as requested more documents. On 06/14/22 RP received all requested documents.

Based on information gathered, LPA finds the allegations to be UNFOUNDED- A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

An exit interview was conducted. and copy of report provided to facility.

Exit Interview conducted.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Misty Valencia	TELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 25-AS-20220613133523

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: SERENITY GARDENS	FACILITY NUMBER: 455002550
	VISIT DATE: 06/16/2022

NARRATIVE

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Staff dispensed the wrong medication to a resident in care

The department investigated the allegation Staff dispensed the wrong medication to a resident in care. During interviews with Administrator (Admin), two (2) staff, and records reviewed, it was determined that, staff dispensed the wrong medication to a resident in care to be substantiated. LPA Valencia had initially received an incident report on a LIC624 on June 10, 2022 regarding the medication error involving resident R1. Through documentation reviewed, it was determined that staff distributed mediation to R1 in error. The facility documented the medication error and did seek medical observation and treatment for R1 following the error.

Based on information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview conducted, appeal rights printed and all documents emailed to Administrator.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Misty Valencia	TELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2022

LIC9099 (FAS) - (06/04)

Page: 5 of 5

Control Number 25-AS-20220613133523

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: SERENITY GARDENS	FACILITY NUMBER: 455002550
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/16/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/17/2022 Section Cited CCR 87465(a)(5)	1 2 3 4 5 6 7	Incidental Medical and Dental Care Services. The licensee shall assist residents with self administered medications when needed.This requirement is not met as evidenced by: based on the fact that staff gave R1 the wrong medication, which poses a This poses an immediate health and safety risk to residents in care.	1 2 3 4 5 6 7	Licensee agrees to conduct a medication distribution traiining for all staff that is scheduled for June 20th and will provide LPA with training information after conducted with staff signatures. Administrator has already trainined the staff who conducted the error.
	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
	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: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Misty Valencia	TELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2022

LIC9099 (FAS) - (06/04)

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