455002677-5-17-2024-59-AS-KHOS-D6FRJK-20240621130401

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 455002677
Report Date: 05/17/2024
Date Signed: 05/17/2024 01:49:25 PM

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
02/21/2024 and conducted by Evaluator Sarah Benson

COMPLAINT CONTROL NUMBER: 59-AS-20240221141404

FACILITY NAME:	HALLMARK NORTH		FACILITY NUMBER:	455002677
ADMINISTRATOR:	SINGH, GURMEEL		FACILITY TYPE:	740
ADDRESS:	920 HALLMARK DR		TELEPHONE:	(530) 243-0147
CITY:	REDDING	STATE: CA	ZIP CODE:	96001
CAPACITY:	6	CENSUS: 5	DATE:	05/17/2024
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Audra Eneix Manager		TIME COMPLETED:	02:10 PM

ALLEGATION(S):

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Medication Management.

INVESTIGATION FINDINGS:

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On 5-17-24, at 1:45PM Sarah Benson, Licensing Program Analyst (LPA) arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 02/21/24. LPA Benson met with Audra Eneix Administrator, and explained the purpose of the visit.

Interviews were conducted and the following documents were reviewed: staff list with telephone numbers, residents admission agreements, medical records, medication administration records, PRN records and incident reports.

continued on 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Sarah Benson	TELEPHONE: 530-895-5033
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024

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-20240221141404

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: HALLMARK NORTH	FACILITY NUMBER: 455002677
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/17/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/17/2024 Section Cited CCR 87466	1 2 3 4 5 6 7	87466 The licensee shall ensure that residents are regularly observed for changes in physical, mental and emotional health and that appropriate assistance is provided...This requirement is not met as exidenced by:	1 2 3 4 5 6 7	Administrator shall have a training of this regulation for staff then contact LPA by POC due date of 6-17-24. Training of carestaff for administratration of medications (PRN) included. Training for carestaff for redirecting residents with behaviors.
	8 9 10 11 12 13 14	Based on observatin and interview of Staff the licensee did not ensure that 1 of 5 residents were regulary observed for changes in physical functioning and that appropriate assistance was provided. This poses a potential health and safety risk to the residents in care.	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: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Sarah Benson	TELEPHONE: 530-895-5033
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 59-AS-20240221141404

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: HALLMARK NORTH	FACILITY NUMBER: 455002677
	VISIT DATE: 05/17/2024

NARRATIVE

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Medication Management.

Document review revealed that after moving to Hallmark North home, Seroquel and Ativan were added to resident’s (R1) medication administration log for agitation.

During staff interviews, it was reported that a staff person gave the resident an Ativan medication, as the resident was combative. After not calming down and approximately 30-40 minutes later, the staff person gave another type of medication, which was Seroquel. It was stated that the Seroquel was an “as needed” type of medication to calm the resident. It was reported that the resident appeared to be kind of “spacey and a little bit out of it.” It was reported in the last five years only one other resident was this agitated.

During witness interviews, it was reported that on 2-10-24 a witness observed the resident in a chair with what seemed to be unconscious state, with her head bent in a way that looked painful. The witness stated when the care staff were asked about the unresponsive condition of resident, the staff responded, "I gave her the medication I was told to give her." The witness couldn't get the resident to respond appropriately, so they took the resident to the hospital where resident was diagnosed as “Over medicated.” Witness reported concern of residents overall sedated condition while in care at the facility. Witness stated previous to living at the facility the resident had been walking one to two miles daily.

During the investigation process, it was determined that the facility staff administered the medication as prescribed by the physician; however, when the resident was taken to the hospital it was reported she was over medicated. The staff did not respond with appropriate assistance when observing the resident slumped over and barely responsive.

The 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.

Exit interview conducted, a copy of the report, and appeal rights provided to administrator.

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Sarah Benson	TELEPHONE: 530-895-5033
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024

LIC9099 (FAS) - (06/04)

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