561703573-10-18-2021-29-AS-KHEN-C87K27-20211027073039

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 561703573
Report Date: 10/18/2021
Date Signed: 10/18/2021 04:24:52 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/14/2021 and conducted by Evaluator Joann Rosales

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20211014100528

FACILITY NAME:	ELMS RESIDENTIAL CARE		FACILITY NUMBER:	561703573
ADMINISTRATOR:	HIGGINS, FE LILIA 98		FACILITY TYPE:	740
ADDRESS:	67 EAST BARNETT		TELEPHONE:	(805) 643-2176
CITY:	VENTURA	STATE: CA	ZIP CODE:	93001
CAPACITY:	54	CENSUS: 43	DATE:	10/18/2021
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Fe Higgins		TIME COMPLETED:	03:50 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff did not assist resident with medications as prescribed

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) JoAnn Rosales conducted a complaint investigation visit at the facility. LPA met with Administrator Fe Higgins.

During today's complaint investigation LPA toured the facility with the Administrator, interviewed random staff and residents and obtained copies of pertinent documents. Concerns were that facility staff did not assist resident #1 (R1) with medications as prescribed as R1 was not assisted with PRN medications when requested. Interview with Administrator on 10/18/21 starting at 1:12 pm revealed that there was 1 or 2 days last week that they refused to give R1 their Ondansetron 4 mg during the PM shift. Administrator stated that R1 requests the medication alot especially at night and feels that the medication should be a scheduled medication. Administrator stated that they spoke with R1's case manager regarding R1's medication. During a review of R1's medications starting at 1:21 pm with the Administrator LPA observed that R1 has 2 medications for Ondansetron 4 mg. The first one indicates place 1 tablet on the tongue and allow to
Continued on 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2021

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 3

Control Number 29-AS-20211014100528

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ELMS RESIDENTIAL CARE	FACILITY NUMBER: 561703573
	VISIT DATE: 10/18/2021

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

dissolve three (3) times daily. The second one indicates take 1 tablet (4 mg total) by mouth every six (6) hours as needed for nausea. A review of R1's medication record for October 2021 indicates Ondansetron 4 mg 1 tab on tongue TID as needed for nausea PRN. R1 was given Ondansetron 4 mg at 7 am on 10/4 - 10/9/21 and 10/11 - 10/17/21 and at 5 pm on 10/13/21. Based on the information obtained during the course of the investigation the allegation is deemed substantiated at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D):

Exit interview was conducted, today's reports and appeal rights were reviewed and emailed to the Administrator.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 29-AS-20211014100528

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ELMS RESIDENTIAL CARE	FACILITY NUMBER: 561703573
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/18/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/19/2021 Section Cited CCR 87465(a)(5)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care Services (a)(5) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator stated that they will provide documentation of scheduled staff medication training to CCL by 10/20/21.
	8 9 10 11 12 13 14	Based on interviews and record review, the licensee did not comply with the section cited above in 1 out of 43 resident medications which poses an immediate health risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3