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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 550307827
Report Date: 09/02/2021
Date Signed: 09/02/2021 10:19:02 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
08/26/2021 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 27-AS-20210826081744
FACILITY NAME:SIERRA FOOTHILLS RESIDENTIAL CARE, INC.FACILITY NUMBER:
550307827
ADMINISTRATOR:DIANA MORECIFACILITY TYPE:
735
ADDRESS:20470 BAY MEADOWS DRIVETELEPHONE:
(209) 533-3708
CITY:SONORASTATE: CAZIP CODE:
95370
CAPACITY:14CENSUS: 13DATE:
09/02/2021
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Diana MoreciTIME COMPLETED:
12:31 PM
ALLEGATION(S):
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Facility staff did not ensure client's medication was refilled in a timely manner

Facility staff did not dispense client's medication as prescribed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarah Hurt arrived to the facility unannounced to open the above allegation. LPA was greeted by facility Administrator Diana Moreci and explained the purpose for today's visit.
After reviewing the residents Medication Administration Record, and also centrally stored medication logs it is determined the facility did not ensure the residents medication was refilled timely causing R1 to be without medication for 2 days. Residents shall be assisted with medications as needed. Based on this the complaint will be SUBSTANTIATED.

Administrator acknowldedges staff did not inform her of R1 being out of medication until the morning after he had missed a dose. R1 missed another dose that evening of the medication therefore facilty did not dispense medication as prescribed. Based on this the complaint will be SUBSTANTIATED.

The following deficiency was cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with facility staff and a copy of this report along with appeal rights was provided.


Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021
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 2
Control Number 27-AS-20210826081744
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: SIERRA FOOTHILLS RESIDENTIAL CARE, INC.
FACILITY NUMBER: 550307827
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/03/2021
Section Cited
CCR
80075(B)
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Health related services. Clients shall be assisted as needed with self administration of prescription and non prescription medications. This requirement has not been met as evidenced by:
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Administrator gave LPA proof that medication was filled. Administrator will submit documents of staff medication documentation, and safely monitioring resident medications trainings.
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based on documentation the facility did not ensure client's medications were refilled timely. Client was withhout medication for 2 days.This poses an immediate risk to 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: Stephenie Doub
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2