374603868-12-27-2021-08-AS-IESA-CB83W8-20220131173620

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603868
Report Date: 12/27/2021
Date Signed: 12/27/2021 12:21:36 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/30/2021 and conducted by Evaluator Anna Kennedy

COMPLAINT CONTROL NUMBER: 08-AS-20210630074825

FACILITY NAME:	COASTAL LIVING		FACILITY NUMBER:	374603868
ADMINISTRATOR:	DEHBOZORGI, ROSHANAK		FACILITY TYPE:	735
ADDRESS:	9486 OWL COURT		TELEPHONE:	(858) 774-3480
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92129
CAPACITY:	6	CENSUS: 4	DATE:	12/27/2021
		UNANNOUNCED	TIME BEGAN:	10:23 AM
MET WITH:	Parvin Dehbozorgi		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Licensee does not destroy medication(s) per regulation.
Licensee does not maintain accurate record of centrally stored medications.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Kennedy and Serrano conducted an unannounced complaint visit to deliver investigative findings regarding the above allegations. LPA identified herself and was invited in to the facility.

LPA met with Parvin Dehbozorgi, Licensee and discussed the purpose of today's visit.

The investigation included, a review of documents, interviews with internal and external sources and a tour of the facility.

It was alleged that the licensee does not destroy medication(s) per regulation. Based on interviews and a review of documentation it was determined that the facility had an excessive amount of PRN (as needed) medication for clients in the facility.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Hedgecock	TELEPHONE: (619)767-2329
LICENSING EVALUATOR NAME: Anna Kennedy	TELEPHONE: (619) 997- 4108
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2021

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 08-AS-20210630074825

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: COASTAL LIVING	FACILITY NUMBER: 374603868
	VISIT DATE: 12/27/2021

NARRATIVE

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The excessive amount of medication was raised as a concern by an outside agency with case management and oversight responsibilities for the clients in the home. Staff 1 (S1) (see LIC 811 for a list of confidential names) destroyed the excess medication. S1 did not document the destruction of the medication on the LIC 622 Centrally Stored Medication and Destruction Record or other equivalent form. S1 did not have the required witness to the destruction. This allegation is Substantiated.

It was further alleged that the licensee does not maintain accurate record of centrally stored medications. Interviews revealed that the licensee had clients with prescribed PRN medications. A review of the medication by an outside agency with case management and oversight responsibilities for the clients in the home discovered that the facility did not have a record of the date and time PRN medication was taken, the dosage taken, and the client's response for any clients in care. This allegation is Substantiated.

A substantiated finding means the allegation is valid because the preponderance of the evidence standard has been met. A deficiency is cited per Title 22, Division 6, Chapter 8 of the California Code of Regulations and is listed on LIC 9099-D.

This report was discussed with Parvin Dehbozorgi, Licensee. A copy along with Licensee Rights (01/2016) was emailed to Ms. Dehbozorgi at the conclusion of the visit. An electronic response confirms the receipt of these documents.

SUPERVISOR'S NAME: Rebecca Hedgecock	TELEPHONE: (619)767-2329
LICENSING EVALUATOR NAME: Anna Kennedy	TELEPHONE: (619) 997- 4108
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2021

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20210630074825

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: COASTAL LIVING	FACILITY NUMBER: 374603868
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/27/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/10/2022 Section Cited CCR 80075(l)	1 2 3 4 5 6 7	Health Related Services - Prescription medications … which are not to be retained shall be destroyed by the facility administrator, or a designated substitute, and one other adult who is not a client. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee will take a class on medication management for licensed facilities. Licensee. will send confirmation by the POC date
	8 9 10 11 12 13 14	Interviews and documents revealed that medication was destroyed without a witness or proper documentation posing a potential risk to the health and safety of 4 of 4 clients in care.	8 9 10 11 12 13 14
Type B 01/10/2022 Section Cited CCR 80075(b)(C)	1 2 3 4 5 6 7	Health Related Services - The date and time the PRN medication was taken, the dosage taken, and the client's response, shall be documented and maintained in the client's facility record. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee will take a class on medication management for licensed facilities. Licensee. will send confirmation by the POC date
	8 9 10 11 12 13 14	Interviews and a document review revealed that the facility did not document PRN medication given to clients posing a potential risk to the health and safety of 2 of 4 clients in care.	8 9 10 11 12 13 14

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: Rebecca Hedgecock	TELEPHONE: (619)767-2329
LICENSING EVALUATOR NAME: Anna Kennedy	TELEPHONE: (619) 997- 4108
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2021

LIC9099 (FAS) - (06/04)

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