486801888-2-15-2024-21-AS-VBEI-D2J299-20240216161133

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486801888
Report Date: 02/15/2024
Date Signed: 02/15/2024 11:45:29 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/11/2024 and conducted by Evaluator David Leibert

COMPLAINT CONTROL NUMBER: 21-AS-20240111095624

FACILITY NAME:	JENSTEPH HOME CARE		FACILITY NUMBER:	486801888
ADMINISTRATOR:	AQUINO, RAFAEL V.		FACILITY TYPE:	740
ADDRESS:	736 ANITA CIR.		TELEPHONE:	(707) 747-6659
CITY:	BENICIA	STATE: CA	ZIP CODE:	94510
CAPACITY:	6	CENSUS: 5	DATE:	02/15/2024
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Rose Aquino		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Facility not following Hospice Care Plan
Resident left in soiled bedding for long periods of time
Staff verbally abusing resident
Facility not following physician orders

INVESTIGATION FINDINGS:

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Licensing Program Analyst Leibert arrives unannounced for the purpose of delivering findings on this complaint. Based upon interviews, site visits, and document reviews, the following determinations are made: Staff state no Hospice Care Plan was left at facility until after January 18; LPA noted no Hospice Plan at facility on Jan. 18; Hospice management state a care plan was left in November, 2023; Following site visit of Jan 18, LPA advised Hospice that no care plan was at facility; LPA noted care plan at facility on subsequent site visit of Jan 23; Complainant has not personally observed Resident (R1) but has suggested several witnesses to R1's neglect; Only one witness( W1) has responded to this Department's request for a statement and W1's statement does not support the allegations of neglect; R1 and R1's bed were clean at three LPA unannounced visits; Facility staff did not document administrations of PRN medication ordered by physician but state that PRN medications were administered according to the physician's orders. Although the allegations may be true, based upon statements, documents, site visits, there is not a preponderance of evidence to prove, or disprove, the allegations. Therefore, allegations are UNSUBSTANTIATED.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

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

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/11/2024 and conducted by Evaluator David Leibert

COMPLAINT CONTROL NUMBER: 21-AS-20240111095624

FACILITY NAME:	JENSTEPH HOME CARE		FACILITY NUMBER:	486801888
ADMINISTRATOR:	AQUINO, RAFAEL V.		FACILITY TYPE:	740
ADDRESS:	736 ANITA CIR.		TELEPHONE:	(707) 747-6659
CITY:	BENICIA	STATE: CA	ZIP CODE:	94510
CAPACITY:	6	CENSUS: 5	DATE:	02/15/2024
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Rose Aquino		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Facility not documenting medication on Centrally Stored Log

INVESTIGATION FINDINGS:

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Licensing Program Analyst Leibert arrives unannounced for the purpose of delivering findings on this complaint. Based upon interviews, site visits, and document reviews, the following determinations are made: On February 01, 2024, a site visit was made to the facility and the Centrally Stored Medication log was reviewed; It was noted that an antibiotic was ordered by the physician for R1 but was not entered and listed on the CSM log which is a Title Twenty-Two requirement. Based upon the document review, the preponderance of evidence standard has been met. Therefore, the allegation is SUBSTANTIATED. The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

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

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 21-AS-20240111095624

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: JENSTEPH HOME CARE	FACILITY NUMBER: 486801888
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/15/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/29/2024 Section Cited CCR 87465(h)(6)	1 2 3 4 5 6 7	87465(h)(6) Incidental Dental and Medical Care. The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year…: Based on document review, this requirement not met as	1 2 3 4 5 6 7	Administration shall provide refresher training on Medications for all staff handling and administering medication and provide proof of training to CCL by POC date in order to clear the deficiency.
	8 9 10 11 12 13 14	evidenced by: Antibiotic ordered for R1 was not documents on the Centrally Stored Medication log. This posed a potential risk to the health of R1.	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: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

LIC9099 (FAS) - (06/04)

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