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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347003298
Report Date: 07/19/2021
Date Signed: 07/19/2021 05:26:54 PM



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
07/15/2021 and conducted by Evaluator Victoria Brown
COMPLAINT CONTROL NUMBER: 27-AS-20210715152905
FACILITY NAME:HAVEN VALLEY CARE AT THE MEADOWSFACILITY NUMBER:
347003298
ADMINISTRATOR:RIVERA, RENATO F. JR.FACILITY TYPE:
735
ADDRESS:2158 JOHN STILL DRIVETELEPHONE:
(916) 665-2748
CITY:SACRAMENTOSTATE: CAZIP CODE:
95832
CAPACITY:6CENSUS: 5DATE:
07/19/2021
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Renato RiveraTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Facility does not have a designated person/Administrator on duty
Licensee failed to administer medications as prescribed
Licensee failed to keep facility clean
INVESTIGATION FINDINGS:
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Prior to arrival at facility Licensing Program Analyst (LPA) Victoria Brown asked the staff the following questions: In the last 10 days, has anyone who is regularly present in the home/facility, including persons in care, or staff developed any of the following symptoms not associated with a pre-existing condition? Fever or chills, Cough, Shortness of breath/difficulty breathing, Fatigue, Muscle or body aches, Headaches, New loss of taste or smell, Sore throat, Congestion or runny nose, Nausea or vomiting, and Diarrhea. Have any individuals Tested positive for COVID-19 with a laboratory confirmed test? Have any individuals Been exposed to someone who tested positive for COVID-19 w/o wearing appropriate PPE? Have any individuals Been diagnosed with a respiratory infection (e.g., flu, bronchitis) or have any respiratory symptoms, such as a sinus congestion or runny nose? Are any individuals in care, caregivers, or staff being evaluated for COVID-19 by a healthcare worker in a healthcare setting? Have any individuals in care, caregivers, or staff been quarantined for COVID-19 in the past 30 days? Have any individuals in care, caregivers, or staff traveled within the last 14 days, to a country considered to be at high-risk for COVID-19 by the CDC travel website? LPA received a "No" answer to all of the above questions.
Substantiated
Estimated Days of Completion: 30
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2021
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 4
Control Number 27-AS-20210715152905
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: HAVEN VALLEY CARE AT THE MEADOWS
FACILITY NUMBER: 347003298
VISIT DATE: 07/19/2021
NARRATIVE
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 7/19/21 at 1:15PM. LPA met with Renato Rivera regarding the purpose of todays visit.

Regarding allegation, “Facility does not have a designated person/Administrator on duty”, LPA observed that on record the Designation of Facility Responsibility (LIC308) indicates that Melly Galeos, Reyn Galeos, Romaine Madrid, and Violeta Rivera is to be in charge of the facility in the absence of the Administrator Renato Rivera. Renato Rivera stated that the LIC308 need to be updated. However, during the hours of 8-12p upon the arrival of a representative(s) from Alta Regional Center there was 2 staff present. In addition, upon the arrival of LPA at 5pm there were 3 staff. LPA requested documentation of the LIC308 and inquired about the administrator at which time the staff contacted Renato Rivera to assist with the visit. Allegation Substantiated

Regarding allegation, “Licensee failed to administer medications as prescribed”, LPA reviewed medications and Medication Administration Record with Renato Rivera, Ronelo Madrid, and Romaine Madrid who was on the phone during this visit. A review of Resident #1(R1) – (R4) medications revealed that an extra dose of Alendronate Sodium 70mg was given, the Levothyroxine bubble pack was not labeled correctly and the pharmacy was not notified, the Linzess dosage was not documented, administered, or labeled with the reason for use correctly, the Guaifenesin 100mg instructions were not clear on when to start the medication or if it was a PRN and the pharmacy was not contacted, the Calmoseptine prescription was not correct, the physician wrote use 2 times a day and the pharmacy wrote take as PRN. During the Regional Center inspection on 7/15/21, S1 confirmed that the documentation was not updated during the time of administering the medication. Renato Rivera and Romaine Madrid confirmed the medications were not reviewed upon receipt. Staff all confirmed that the medication errors and documentation errors were consistent with the findings of Alta Regional Centers inspection the morning of 7/15/21. Allegation Substantiated

Regarding allegation, “Licensee failed to keep facility clean”, LPA obtained information that S2 had feces soiled chucks on the floor which was not disposed of properly. In addition, LPA toured the facility and took pictures of the corners of the floors where there was dirt embedded and dried on the floor(s). Renato Rivera stated that the floors are mopped daily but can be buffed out. The cabinets door had patches of dirt embedded on them. Items used as decorations that were hanging on the walls had an excessive amount of dust on them. Allegation Substantiated
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20210715152905
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: HAVEN VALLEY CARE AT THE MEADOWS
FACILITY NUMBER: 347003298
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/19/2021
Section Cited
CCR
85064(f)
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Administrator Qualifications and Duties
When the administrator is absent from the facility there shall be coverage by a designated substitute, who meets
the qualifications of Section 80065, who shall be capable of, and responsible and accountable for, management and
administration of the facility in compliance with applicable law and regulation.
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The Licensee/Administrator shall submit an updated LIC500 and LIC308 by close of business today 7/19/21.
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This requirement is not met as evidenced by: Upon arrival to the facility, LPA observed that there was no coverage by a designee. Based on a visit from Alta Regional Center in the morning and CCL in the evening the facility did not have a Designee nor Administrator present. This violation poses an immediate health, and safety risk to residents in care.
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Type A
07/19/2021
Section Cited
CCR
80075(6)(D)(1-4)
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Health Related Services
If the client is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the client with self-administration, provided all of the following requirements are met:
For every prescription and nonprescription PRN medication for which the licensee provides assistance,
there shall be a signed, dated written order from a physician on a prescription blank, maintained in the client's file, and
a label on the medication. Both the physician's order and the label shall contain at least all of the following information.
(1) The specific symptoms which indicate the need for the use of the medication.
(2) The exact dosage.
(3) The minimum number of hours between doses.
(4) The maximum number of doses allowed in each 24-hour period.
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The Licensee/Administrator shall contact the pharmacy to ensure all prescriptions are correctly labeled, the Centrally Stored Medication Record is completed accurately along with the use of a MARs. Administrator shall train staff on medication administration. Proof shall be submitted to CCL by POC due date.
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This requirement is not met as evidenced by: Medications were missed, and extra dose given, prescriptions not correct from pharmacy not addressed, and medication record not completed timely
Based on confirmation from S1, Administrator and S5 the facility did not remain in compliance
This violation poses an immediate health, and safety 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.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20210715152905
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: HAVEN VALLEY CARE AT THE MEADOWS
FACILITY NUMBER: 347003298
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/19/2021
Section Cited
CCR
80087(a)
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Buildings and Grounds
The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
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The Licensee/Administrator shall provide training to staff on safety precautions. Proof shall be submitted to CCL by POC due date
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This requirement is not met as evidenced by: S2 had feces soiled chucks on the floor which was not disposed of properly
Based on observation that the facility staff did not remove the soiled chucks timely
This violation poses an immediate health, and safety 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.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4