<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803977
Report Date: 09/22/2021
Date Signed: 09/24/2021 01:54:41 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/10/2021 and conducted by Evaluator Araceli Canela
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20210910123603
FACILITY NAME:JPS HOME CARE SERVICESFACILITY NUMBER:
486803977
ADMINISTRATOR:PIMENTEL, LOLITAFACILITY TYPE:
740
ADDRESS:441 NORTH CAMINO ALTOTELEPHONE:
(707) 655-2264
CITY:VALLEJOSTATE: CAZIP CODE:
94590
CAPACITY:6CENSUS: 5DATE:
09/22/2021
UNANNOUNCEDTIME BEGAN:
10:01 AM
MET WITH:Bernabe BuenviajeTIME COMPLETED:
12:57 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not administering medication(s) to resident as prescribed by their physician.

Staff are not maintaining resident's medical records as required.



INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA), A. Canela arrived unannounced
on 9/22/2021 at 10:00 AM, for the purpose of gathering additional information and delivering findings to the allegations listed above. LPA met with, care staff Bernabe Buenviaje, Administrator and licensee were not available during this visit.

It was alleged staff are not administering medication(s) to resident as prescribed by their physician. During a previous inspection to the facility on 9/14/2021; LPA conducted a medication audit for 2 of 5 residents and reviewed records. Based on medication audit and interview with the Licensee, it was found that resident R1 was not given a prescribed medication (Metformin, Docusate) or the wrong doze was provided for (Clozapine). Facility is not using the Medication Administration Record "MAR" to log/record after the medication has been provided to the residents and were unable to determine what was given daily to R1.

See LIC9099- C for continued report
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021
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 4
Control Number 21-AS-20210910123603
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: JPS HOME CARE SERVICES
FACILITY NUMBER: 486803977
VISIT DATE: 09/22/2021
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
26
27
28
29
30
31
32
 LPA found bubble pack with some medication left in it and licensee confirmed the resident R1 received some of their medication, but does not understand what happened or why medication mentioned above was not provided to R1.

It was also alleged staff are not maintaining resident's medical records as required. LPA requested to view 5 resident files on 9/14/2021, and licensee, Evelyn Serrano informed LPA, she did not have the medical records, Physicians reports for 2 residents, R2 and R3.

Based on LPA’s observations, review of medications and record review of 9/14/21 and today 9/22/21, the preponderance of evidence standard has been met, therefore the allegations for staff are not administering medication(s) to resident as prescribed by their physician and staff are not maintaining resident's medical records as required are both found to be 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 and this report will be emailed to facility due to printer problems.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 21-AS-20210910123603
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: JPS HOME CARE SERVICES
FACILITY NUMBER: 486803977
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/23/2021
Section Cited
CCR
87465(a)(5)
1
2
3
4
5
6
7
87465(a)(5) Incidental Medical and Dental Care-A plan for incidental medical & dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self-administered medications as needed.
1
2
3
4
5
6
7
Facility to send in written plan on how they will ensure compliance and written plan for medication training. First POC due date 9/23/2021 with follow up by 9/30/2021 for proof of medication training.

8
9
10
11
12
13
14
This requirement was not met- As evidenced by: During medication audit of 9/14/21 an d today 9/22 the facility failed to provide some medication to R1. (Metaformin, Docusate & Clozapinerx) was not provided, or correct doze was not provided.
This is an immediate risk to the Health & Safety of residents in care
8
9
10
11
12
13
14
Type B
09/30/2021
Section Cited
CCR
87458(a)
1
2
3
4
5
6
7
87458(a) Medical Assessment- Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.
1
2
3
4
5
6
7
Facility to send in written statement they understand regulation and how they will ensure compliance and have all required records for all residents.
8
9
10
11
12
13
14
This requirement was not met as evidenced by:
During facility resident record review, 2 of 5 residents did not have the required Physician report for R2 and R3.
This is a potential risk to the Health & Safety of residents in care
8
9
10
11
12
13
14
POC due date 10/12/2021 to LPA A. Canela
FAx (707) 588-5080 or by email: araceli.canela@dss.ca.gov
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: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/10/2021 and conducted by Evaluator Araceli Canela
COMPLAINT CONTROL NUMBER: 21-AS-20210910123603

FACILITY NAME:JPS HOME CARE SERVICESFACILITY NUMBER:
486803977
ADMINISTRATOR:PIMENTEL, LOLITAFACILITY TYPE:
740
ADDRESS:441 NORTH CAMINO ALTOTELEPHONE:
(707) 655-2264
CITY:VALLEJOSTATE: CAZIP CODE:
94590
CAPACITY:6CENSUS: 5DATE:
09/22/2021
UNANNOUNCEDTIME BEGAN:
10:01 AM
MET WITH:Bernabe BuenviajeTIME COMPLETED:
12:57 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Medication is not centraly stored.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA), A. Canela arrived unnanounced
on 9/22/2021 at 10:00 AM, for the purpose of delivering findings to the allegation listed above. LPA met with care staff, Bernabe Buenviaje; Administrator and licensee were not available during this visit.

It was alleged medication is not centrally stored. LPA conducted an inspection on 9/14/2021 and observed medication cabinet with medication and Administrators office room with additional medication. Licensee explained they had some medication in the administrators room, because they were reviewing medication and logging in new medication. Licensee also explained medication is centrally stored in the kitchen medication cabinet. On today's inspection LPA observed mediaction centrally stored and received statements from 3 of 5 residents and 3 of of 3 staff and all corroborated the medication is all kept in the locked kitchen medication cabinet. This Agency has investigated the complaint alleging "Medication is not centraly stored". We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.
No deficiencies cited related to this complaint during today’s visit.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4