565801257-5-11-2022-29-AS-DPEA-CGQLJV-20220727084835

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565801257
Report Date: 05/11/2022
Date Signed: 05/11/2022 03:22:54 PM

Unsubstantiated

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
11/10/2021 and conducted by Evaluator Kasandra Lopez

COMPLAINT CONTROL NUMBER: 29-AS-20211110101421

FACILITY NAME:	EJ2 FAMILY HOME		FACILITY NUMBER:	565801257
ADMINISTRATOR:	MARIA MIRANDA		FACILITY TYPE:	735
ADDRESS:	1210 NELSON PLACE		TELEPHONE:	(805) 271-9449
CITY:	OXNARD	STATE: CA	ZIP CODE:	93033
CAPACITY:	6	CENSUS: 6	DATE:	05/11/2022
		UNANNOUNCED	TIME BEGAN:	08:53 AM
MET WITH:	Erik Miranda		TIME COMPLETED:	09:50 AM

ALLEGATION(S):

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Staff is not meeting the needs of the resident.
Staff is not adhering to Doctor's orders.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced subsequent complaint inspection at the facility to deliver findings for the above allegations. The LPA met with Co-Administrator Erik Miranda at 8:53 AM and explained the reason for the inspection.

During the course of the investigation, the LPA conducted two previous inspections for this complaint the Department received on 11/10/2021. On 11/16/2021, beginning at 10:02 AM, the LPA conducted an interview with Administrator Maria Miranda and at 10:19 reviewed facility and medication records. On 11/22/2021, the LPA conducted interviews with Resident #1 (R1) at 8:50 AM and with Staff #1 (S1) at 9:25 AM.

Report continued on LIC 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2022

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 29-AS-20211110101421

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: EJ2 FAMILY HOME	FACILITY NUMBER: 565801257
	VISIT DATE: 05/11/2022

NARRATIVE

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The allegation of ‘Staff is not meeting the needs of the resident’ alleges, R1 was in pain and not receiving timely medical treatment for an ingrown toenail and R1 has swollen feet. During the interview with R1, R1 stated when they informed staff their toenail was growing into their skin, staff made an appointment right away for R1 to be seen and R1 was seen by the podiatrist on 11/21/2021. R1 also stated during the interview, their ankles swell when their socks are too tight. Record review revealed R1 sees their podiatrist routinely every two months, with the previous appointment being on 09/24/2021. During the interview with the Administrator, she stated R1’s feet swell intermittently and R1’s physician was aware of the situation and prescribed R1 medication for the condition in the past. Record review also revealed R1 sees their physician routinely. Based on the information obtained during the investigation, there is insufficient evidence to support the allegation occurred. Therefore, the allegation is deemed unsubstantiated at this time.

The allegation of ‘Staff is not adhering to Doctor's orders’ alleges staff are giving R1 all their medication in the morning instead of the time period the physician ordered. Record review revealed R1 takes approximately 13 different medications daily, which are prescribed at various times, including morning, late afternoon, and bedtime. Medication administration records completed by staff indicate medications are being given at the correct time they are prescribed. During the interview with R1, R1 stated they receive their medication in the morning, in the afternoon, and at night. During the interview with S1, they stated R1’s medications are given as prescribed. S1 also stated due to changes in R1’s mental health, there have been changes to medications recently. Based on the information obtained during the investigation, there is insufficient evidence to support the allegation occurred. Therefore, the allegation is deemed unsubstantiated at this time.

Exit interview and report reviewed with Erik Miranda. A copy of the report was emailed.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2022

LIC9099 (FAS) - (06/04)

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