079200834-10-10-2023-15-AS-KHOS-CWPHM6-20231017061836

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200834
Report Date: 10/10/2023
Date Signed: 10/10/2023 12:02:26 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/06/2023 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20231006135801

FACILITY NAME:	TERRACE VIEW ASSISTED LIVING		FACILITY NUMBER:	079200834
ADMINISTRATOR:	MICHAELSON, MANJULA		FACILITY TYPE:	740
ADDRESS:	2828 TERRACE VIEW AVE		TELEPHONE:	(925) 354-0403
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94531
CAPACITY:	3	CENSUS: 2	DATE:	10/10/2023
		UNANNOUNCED	TIME BEGAN:	11:50 AM
MET WITH:	Manjula Michaelson, Administrator		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Staff mismanaged resident's medication

INVESTIGATION FINDINGS:

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On 10/10/23 at 11:50AM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit, met with administrator (ADM), gathered information and delivered investigation findings to ADM. LPA explained the purpose of the visit with ADM.

During visit, the department obtained the following documents from administrator - staff roster, residents' roster, admission agreements, physicians reports, ID/Emergency information, hospital discharge reports, Centrally stored medication logs and Medication administration records

Continued on next page, LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

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 15-AS-20231006135801

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: TERRACE VIEW ASSISTED LIVING	FACILITY NUMBER: 079200834
	VISIT DATE: 10/10/2023

NARRATIVE

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Allegation: Staff mismanaged resident's medication
Investigation Finding: Unsubstantiated
During investigation, LPA interviewed staff (ADM) who stated she did not replace residents' prescribed medications with herbal supplements nor stop administering their prescribed & PRN medications.

Review of R1 & R2's centrally stored medication logs and medication administration records dated 04/2023 until 10/2023 show staff assists both residents with taking prescribed and over the counter medications in accordance with physicians' instructions.

Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff mismanaged resident's medication and found it to be unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff mismanaged resident's medication is unsubstantiated.

Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

LIC9099 (FAS) - (06/04)

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