496803828-5-27-2022-21-AS-KMOA-CGBM6Y-20220714092041

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803828
Report Date: 05/27/2022
Date Signed: 05/27/2022 03:10:08 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
03/21/2022 and conducted by Evaluator Erik Gonzalez Campos

COMPLAINT CONTROL NUMBER: 21-AS-20220321112143

FACILITY NAME:	RINCON VALLEY GUEST HOME		FACILITY NUMBER:	496803828
ADMINISTRATOR:	POPAT, SABRINA		FACILITY TYPE:	740
ADDRESS:	996 ESTES DR		TELEPHONE:	(707) 539-6247
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95409
CAPACITY:	6	CENSUS: 4	DATE:	05/27/2022
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Staff, Marlene Guido		TIME COMPLETED:	03:20 PM

ALLEGATION(S):

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Medication is not being dispensed per regulations

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unnanounced on 05/27/2022 to conduct an investigation regarding the allegation mentioned above. LPA met with Staff, Marlene Guido. Administrator/Licensee, Sabrina Popat was notified over the phone.

There was an allegation that medication is not being dispensed per regulation. During the inspection on 05/27/2022 LPA conducted record review and interviews. Record review revealed that Resident (R1) was prescribed Methenamine Hippurate, to be started on 02/07/2022. R1 is to be given medication two times daily, with breakfast and dinner. Medication administration record (MAR) indicated that R1 has been given medication once a day at 8AM during the month of May.

Medication bottle was inspected, label instructs to give medication twice a day.

Continued on LIC 9099C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez Campos	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022

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 21-AS-20220321112143

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: RINCON VALLEY GUEST HOME	FACILITY NUMBER: 496803828
	VISIT DATE: 05/27/2022

NARRATIVE

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R1 was also prescribed Bismuth Subsalicylate. An addendum to his medication orders directed that the Bismuth Subsalicylate be discontinued on 05/06/2022. Doses were given on 05/07/2022, 05/08/2022, and 05/09/2022.

The preponderance of evidence standard has been met, therefore the above allegation is SUBSTANTIATED. California Code of Regulations, Title 22, is being cited on the attached LIC 9099-D. Appeal Rights Given.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez Campos	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20220321112143

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: RINCON VALLEY GUEST HOME	FACILITY NUMBER: 496803828
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/27/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 05/30/2022 Section Cited CCR 87465(c)	1 2 3 4 5 6 7	87465(c) Incidental Medical and Dental Care....shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee agrees to submit training date for Medication Administration training by an outside vendor by POC date of 05/30/2022. Licensee agrees to submit proof of training to CCL by 06/10/2022. Licensee agrees to submit proof of training to CCL by 06/10/2022.
	8 9 10 11 12 13 14	Based on LPA interview, record review and observation, Licensee failed to ensure R1's prescribed medication was given and documented due to discrepancies in the MAR. This poses an immediate risk to the Health, Safety or Personal Rights of residents in care.	8 9 10 11 12 13 14
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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.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez Campos	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022

LIC9099 (FAS) - (06/04)

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