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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200735
Report Date: 05/14/2021
Date Signed: 05/14/2021 03:23:37 PM

Document Has Been Signed on 05/14/2021 03:23 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:CALIFORNIA MENTOR - MALABAR HOMEFACILITY NUMBER:
019200735
ADMINISTRATOR:CHRISTINE CARVAJALFACILITY TYPE:
740
ADDRESS:4639 MALABAR AVETELEPHONE:
(909) 483-2505
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94546
CAPACITY: 4CENSUS: 4DATE:
05/14/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:21 AM
MET WITH:Joe FarrishTIME COMPLETED:
03:15 PM
NARRATIVE
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On 05/14/2021 Licensing Program Analyst (LPA) Allison O'Hollaren conducted an unannounced case management visit regarding a self reported incident that occurred on 05/09/2021. Due to the Shelter in Place set forth by the Governor on March 17, 2020, LPA was not able to conduct the visit in person. The visit was performed by telephone. LPA spoke with Administrator, Joe Farrish.

During the phone call LPA spoke and reviewed incident with Administrator. Administrator confirmed that R1 was given R1's PM medications instead of AM medications in the morning. The error was discovered fifteen minutes later.

The following deficiency was cited from the California Code of Regulations, Title 22. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report emailed.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Allison O'Hollaren
LICENSING EVALUATOR SIGNATURE: DATE: 05/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/14/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/14/2021 03:23 PM - It Cannot Be Edited


Created By: Allison O'Hollaren On 05/14/2021 at 09:30 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CALIFORNIA MENTOR - MALABAR HOME
FACILITY NUMBER: 019200735

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/28/2021
Section Cited
CCR
87465(c)(2)

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87465 (c) If the resident's physician has stated in writing... facility staff designated ...shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once
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Facilty LVN has already conducted a facility-wide staff training on medication management. In addition, Administrator agrees to send an individual medication training plan for S1 to CCLD by POC date.
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ordered...the medication is given according to the physician's directions. This requirement was not met as evidenced by: Based on LPA interview Staff (S1) did not comply with the regulation stated above which poses a potential health and safety risk to the resident.
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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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Allison O'Hollaren
LICENSING EVALUATOR SIGNATURE:
DATE: 05/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2021


LIC809 (FAS) - (06/04)
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