565800682-3-15-2023-29-AS-DPEA-CRASZD-20230427141859

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565800682
Report Date: 03/15/2023
Date Signed: 03/15/2023 06:21:26 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, 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
03/09/2023 and conducted by Evaluator Kelly Dulek

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20230309133353

FACILITY NAME:	ALMAVIA OF CAMARILLO		FACILITY NUMBER:	565800682
ADMINISTRATOR:	MATTHEW HATHWAY		FACILITY TYPE:	740
ADDRESS:	2500 NORTH PONDEROSA DRIVE		TELEPHONE:	(805) 388-5277
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93010
CAPACITY:	100	CENSUS: 71	DATE:	03/15/2023
		UNANNOUNCED	TIME BEGAN:	09:53 AM
MET WITH:	Matthew Hathway		TIME COMPLETED:	06:25 PM

ALLEGATION(S):

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Facility staff did not assist resident with self-administration of medications as prescribed

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kelly Dulek conducted an initial complaint investigation for the allegation listed above. LPA arrived at the facility at 09:53AM and met with Executive Director Matthew Hathway. Entrance interview conducted.

During today's visit, LPA interviewed Executive Director at 09:55AM, toured the facility with Executive Director Hathway at 10:23AM, conducted staff interviews at 10:34AM, 10:45AM, 11:15AM, and 04:14PM, reviewed medications at 11:31AM and 05:21PM, LPA reviewed Resident #1 (R1)'s file at 11:51AM, gathered copies of pertinent documents, interviewed R1 at 04:18PM, witness at 04:20PM, and R1's family member at 04:42PM. The following was then determined:

It was alleged that on 03/08/2023, R1's routine morning medications were not administered timely. Interview revealed that a new medication technician was being trained on that date and was shadowing
Report Continued on LIC 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023

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 29-AS-20230309133353

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: ALMAVIA OF CAMARILLO	FACILITY NUMBER: 565800682
	VISIT DATE: 03/15/2023

NARRATIVE

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another staff during the daytime shift. R1 received their PRN Lorazepam at 09:17AM. However, record review and interview revealed that R1 takes regularly prescribed medications at 10:30AM. Interview revealed that due to the timing of the medication, the electronic Medication Administration Record (MAR) has these medications listed under the noon medication pass rather than the morning medication pass. Interview revealed that after administering facility residents' noon medications, Staff #1 (S1) was reviewing the noon medication pass when S1 realized R1 had not yet received their 10:30AM medications. S1 then offered R1 their medications. Medications were recorded on the electronic MAR at 01:40PM indicating "resident refused." However, interview revealed that R1 did in fact receive their medications outside the designated morning time frame. Additionally, LPA conducted a medication review during today's visit beginning at 11:31AM. The following was noted: R1's Quetiapine Fumarate 25mg was opened on 03/07/2023 and initially contained 30 doses, as each dose is 1/2 pill. During today's medication review, LPA and Med Tech counted 22 remaining doses, which is one extra dose of this medication. MAR review revealed that there were no missed doses of this medication during the time frame indicated, with the exception of the late medications on 03/08/2023. Similarly, there were one extra remaining dose of R1's medications as follows: Gabapentin 100mg, Furosemide 20mg, Metopropol Succinate ER 25mg, Pantoprozole Sod DR 40mg, Potassium Chloride ER 8 MEQ, and Spironolactone 25mg. For each of the above listed medications, the dosage indicated under #11 in the bubble pack remains. As the MAR is initialed as administered, it is unclear whether R1 refused these medications or if the medications were offered to R1. Based on interview and record review, the allegation that "Facility staff did not assist resident with self-administration of medications as prescribed" is deemed SUBSTANTIATED at this time.

The following deficiency was observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Failure to correct the deficiency may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230309133353

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: ALMAVIA OF CAMARILLO	FACILITY NUMBER: 565800682
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/15/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/29/2023 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465 (a) A plan for incidental medical and dental care shall be developed by each facility....such care, by compliance with the following:(4) 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	S1 is no longer employed by the facility as of 03/12/2023. Administrator agreed to provide medication training to all medication technicians and provide proof of training to CCL by 03/29/2023.
	8 9 10 11 12 13 14	Based on interview and record review, the facility did not comply with the above cited section, as R1's morning meds were late on 03/08/2023 and 6 of R1's medications reviewed contained one more dose than the amount administered, which poses an immediate health risk to residents 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: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023

LIC9099 (FAS) - (06/04)

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