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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803525
Report Date: 06/27/2023
Date Signed: 06/27/2023 05:48:19 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, 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
06/21/2023 and conducted by Evaluator Dominic Tobola
COMPLAINT CONTROL NUMBER: 21-AS-20230621104814
FACILITY NAME:DARWIN FACILITYFACILITY NUMBER:
486803525
ADMINISTRATOR:HALL, MYRTLEFACILITY TYPE:
735
ADDRESS:1612 TUCSON CIRCLETELEPHONE:
(707) 426-4981
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY:4CENSUS: 2DATE:
06/27/2023
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Myrtle Hall, LicenseeTIME COMPLETED:
05:45 PM
ALLEGATION(S):
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Licensee failed to ensure client received needed medical services
INVESTIGATION FINDINGS:
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On 6/27/2023 Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of initiating complaint investigation and was greeted by Licensee, Myrtle Hall and Lead Staff, Joanna Hall. LPA toured the facility, interviewed staff and outside parties, gathered resident and North Bay Regional Center (NBRC) documents and made observations.

Complaint alleges Licensee failed to ensure client (C1) received needed medical services. Based on a review of NBRC records, LPA found that the facility undergone a quality insurance inspection where it was determined that C1 had not received prescribed health condition medications for approximately 3 months. Upon interview with staff (S1), LPA found that C1 was assigned a new Psychiatrist and Primary Care Physician (PCP) resulting in C1's prescription medications in need of updating. In March 2023, C1 had completed the last supply of medications but was unable to acquire an updated prescription or refills from C1's PCP due to PCP unavailable for in-person visits until August 2023, and refusing to prescribe medications over the phone. Continued onto LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2023
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 21-AS-20230621104814
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: DARWIN FACILITY
FACILITY NUMBER: 486803525
VISIT DATE: 06/27/2023
NARRATIVE
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Upon review of C1's Medication Administration Records, it was found that facility staff input "stopped by doctor" for several medications (Levothyroxine, Hydroclorothazide & Pravastatin), indicating that C1 had not received these medications from 4/1/2023 through 6/21/2023. A letter from C1's Psychiatrist stated that they did not feel comfortable prescribing C1 with the medication, however also noted that "it does not mean the patient should not be taking these medications", and highly recommends the facility follow up with C1's PCP for appropriate assessment and prescription. The Psychiatrist's letter indicated that the prescription is to be deferred to C1's PCP, but did indicate to discontinue or end the prescriptions (Levothyroxine, Hydroclorothazide & Pravastatin) for C1.

Although the facility had been in contact with C1's care providers, Psychiatrist and PCP; the facility failed to properly contact NBRC and Community Care Licensing (CCLD) in a timely manner to address C1's needs, health and safety. Facility failed to report the incident CCLD and other appropriate parties for several weeks. This resulted in C1 not receiving needed medical services and prescribed medications for approximately 3 months.

Allegation, Licensee failed to ensure client received needed medical services is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. Appeal Rights Given
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20230621104814
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: DARWIN FACILITY
FACILITY NUMBER: 486803525
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/28/2023
Section Cited
CCR
80075(a)
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80075(a) Health Related Services. Each client shall receive necessary first aid and medical or dental services, including arrangement for and/or provision of transportation to the nearest available services. This requirement is not met as evidenced by: Based on interviews and review of facility, resident and outside
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Licensee failed to ensure client C1 received needed medical services. Licensee has scheduled a televisit with C1's physician on 7/12/2023 to discuss C1's prescriptions. Licensee is to submit an action plan on how they will ensure C1 will receive needed medical services and updated prescriptions.
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agency/organization records, it was found that the facility failed to contact appropriate services in a timely manner resulting in client C1 not receiving needed medical services and prescribed medications for approximately 3 months. This is an immediate health & safety risk to clients in care.
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Plan to be submitted to CCLD by POC date 6/28/2023.
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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: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3