480111090-8-30-2021-21-AS-CARD-C6DQ5V-20210830115234

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 480111090
Report Date: 08/30/2021
Date Signed: 08/30/2021 11:52:47 AM

Document Has Been Signed on 08/30/2021 11:52 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME:	GILCREST GROUP HOME, THE		FACILITY NUMBER:	480111090
ADMINISTRATOR:	CHERYL DAVIDSON		FACILITY TYPE:	735
ADDRESS:	447 GILCREST		TELEPHONE:	(707) 563-5543
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94591
CAPACITY: 9		CENSUS: 7	DATE:	08/30/2021
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Jackie Morris		TIME COMPLETED:	11:45 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On August 30, 2021, Licensing Program Analyst (LPA) Chris Arnhold conducted an unannounced case management visit to follow up on a substantiated allegation pertaining to a client (C1) failure to receive medication. On June 29, 2018, the Department concluded a complaint investigation which alleged that the licensee allowed client’s medication to run out which resulted in C1’s hospitalization from April 9, 2018 to April 25, 2018. The allegation was substantiated, and the licensee was cited for violating the California Code of Regulations (CCR) Title 22, § 80075(b) for Health Related Services, which requires that “Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.” C1 did not receive C1’s medication. The investigation revealed that C1 had an admission agreement with the facility date January 17, 2018. The Admission Agreement notes under section 2(d) indicate “Assistance as needed with taking prescribed medications in accordance with physician’s instructions unless prohibited by law or regulations”. C1’s Physician’s Report dated January 16, 2018, lists the above three medications among other medications. The Medication Administration Record (MAR) for March was also reviewed and showed one medication (Metoprol) with the last dose given on March 1, 2018, with the notation “DC (discontinued)”. Two other medications (Glipizide and Lovastatin) last doses were March 2, 2018. Glipizide with the notation “prescription was not renewed on March 1, 2018” and Lovastatin with the notation “DC (discontinued).” Multiple staff and witness interviews were conducted, and pharmacy records were reviewed. The investigation revealed that C1’s medications were arriving on a weekly basis until staff noted that the pharmacy did not refill the medications in March 2018. Facility staff (S1) informed LPA during an interview on April 17, 2018 that S1 attempted to contact C1’s responsible party (RP) and a message was left on RP’s cell phone and work phone. S1 never heard back from responsible party so it was assumed the medication was discontinued. C1’s responsible party stated that they did not receive a call or message from S1. Continued on LIC89-C...

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2021

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

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: GILCREST GROUP HOME, THE	FACILITY NUMBER: 480111090
	VISIT DATE: 08/30/2021

NARRATIVE

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On April 9, 2018, after C1 consumed a soda beverage at day program, C1 vomited multiple times and appeared to be confused. C1 was transported and admitted to a general acute care hospital. Hospital records indicate a diagnosis of diabetic ketoacidosis at 1:17 p.m. According to the Mayo Clinic, “Diabetic ketoacidosis is a serious complication of diabetes that occurs when your body produces high levels of blood acids called ketones. The condition develops when your body can't produce enough insulin. Insulin normally plays a key role in helping sugar (glucose) — a major source of energy for your muscles and other tissues — enter your cells. Without enough insulin, your body begins to break down fat as fuel. This process produces a buildup of acids in the bloodstream called ketones, eventually leading to diabetic ketoacidosis if untreated.” The Mayo Clinic also states, “Diabetic ketoacidosis is life-threatening.”
The investigation revealed the facility did not provide and assist with three of C1’s medications (Glipizide, Metoprol and Lovastatin). The medications were not refilled and C1 went without the medications for a period exceeding thirty days. The Medication Administration Record (MAR) obtained during the investigation for March 2018 indicated C1’s Glipizide was “DC” (discontinued) “prescription was not renewed on March 1, 2018” and last dose was given March 2, 2018 and C1 was hospitalized on April 9, 2018 until April 25, 2018. The medication Glipizide is defined by Mayo Clinic as, “Glipizide is used to treat high blood sugar levels caused by a type of diabetes mellitus (sugar diabetes) called type 2 diabetes.”The Department’s contact with the pharmacy during the investigation revealed that a one-month supply of medications was prescribed by a doctor who was not the primary care physician and a follow up appointment with the primary care physician was needed. This information was provided to S1 on February 23, 2018. The facility could not produce any documentation from the physician to show, the medications were discontinued, or certain medications would not be renewed. Furthermore, staff did not contact the pharmacy to confirm whether the medications were discontinued or the reason why the medications were not renewed or continue to follow up with the responsible party as to the status of the medication. Therefore, C1 did not receive above stated three medications. One of which, is prescribed to manage C1’s diabetes, resulting in C1’s hospitalization, and diagnosis of diabetic ketoacidosis on April 9, 2018. Continued on LIC809-C.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2021

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: GILCREST GROUP HOME, THE	FACILITY NUMBER: 480111090
	VISIT DATE: 08/30/2021

NARRATIVE

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Based on interviews with facility staff, witnesses, medical social worker, pharmacy and a review of the facility and medical records, the Department confirmed the facility did not ensure C1 did not use the prescribed medication as ordered by C1’s physician resulting in diabetic ketoacidosis that required hospitalization which is a serious bodily injury.

The complaint was delivered on June 29, 2018. The report was amended on July 25, 2018 and an immediate civil penalty of $500 was issued. On this day the licensee was informed that additional civil penalties are still being determined and might be assessed based on Health and Safety Code § 1548.
The Department has concluded an analysis and has determined that an additional civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code § 15610.67 defines serious bodily injury as, “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including, but not limited to, hospitalization, surgery, or physical rehabilitation.”
Today, August 30, 2021 the Department will be issuing a civil penalty per Health and Safety Code § 1548, for a violation that the Department constitutes as a serious bodily injury in the amount of $10,000. However, since a civil penalty of $500 was previously issued on July 25, 2018, the amount of the civil penalty issued today will be $9,500.
Exit interview conducted. A copy of the report issued. Appeal Rights provided. (facility representative) signature on this report acknowledges receipt of the Appeal Rights, found on page two of LIC 421D”

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2021

LIC809 (FAS) - (06/04)

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