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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 500332206
Report Date: 02/23/2023
Date Signed: 02/23/2023 01:59:29 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/16/2023 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20230216135141
FACILITY NAME:DEL RIO GUEST HOMEFACILITY NUMBER:
500332206
ADMINISTRATOR:SILER, DOROTHYFACILITY TYPE:
735
ADDRESS:2841 PATTERSON RDTELEPHONE:
(209) 869-2420
CITY:RIVERBANKSTATE: CAZIP CODE:
95367
CAPACITY:15CENSUS: 11DATE:
02/23/2023
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Saudia WhitakerTIME COMPLETED:
02:10 PM
ALLEGATION(S):
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Staff mismanaged resident's medications.
INVESTIGATION FINDINGS:
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On 2/23/23 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to open a complaint investigation in to the above listed allegation. LPA Jensen met with Licensee Saudia Whitaker and explained the purpose of today's visit.

LPA Jensen interviewed the Licensee and reviewed an incident report received by the Department on 2/9/23. LPA Jensen reviewed the Medication Administration Records (MARS) for Resident 1 (R1) and Resident 2 (R2). Based on the interview conducted and records reviewed, LPA Jensen determined that on 2/3/23 Staff 1 (S1) had medications for both R1 and R2 out for administering to the residents. S1 gave inadvertently gave the R2's medication to R1 and it was ingested. S1 gave R2 the medication for R1 and R2 recognized that it was incorrect and did not ingest the medications. The Licensee conducted an internal investigation and determined that S1 did not follow facility protocol for medication administration.

Continued on LIC 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023
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 27-AS-20230216135141
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: DEL RIO GUEST HOME
FACILITY NUMBER: 500332206
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/24/2023
Section Cited
CCR
80075(b)
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Health Related Services
...Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.
This requirement was not met as evidenced by:
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The Licensee agrees to submit a plan for all staff to undergo medication training either by an outside vendor or in-service to maja.jensen@dss.ca.gov by POC due date. The medication training must be concluded by 3/23/23. The Licensee has suspended S1.
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Based on the Licensee's self reporting of a resident receiving medication from staff and ingesting medication prescribed to a different resident on 2/3/23. This poses an immediate risk to the health, safety and personal rights of residents in care.
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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: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20230216135141
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: DEL RIO GUEST HOME
FACILITY NUMBER: 500332206
VISIT DATE: 02/23/2023
NARRATIVE
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Continued from LIC 9099...

The Licensee took disciplinary action on S1 for the breach of protocol. This allegation is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met.

Deficiencies are being cited form the California Code of Regulations (CCR) Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties.

An exit interview was conducted and a copy of this report and appeal rights were given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3