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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200735
Report Date: 11/22/2023
Date Signed: 11/22/2023 01:46:17 PM

Substantiated


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
11/16/2023 and conducted by Evaluator Kelly Nguyen
COMPLAINT CONTROL NUMBER: 15-AS-20231116151906
FACILITY NAME:CALIFORNIA MENTOR - MALABAR HOMEFACILITY NUMBER:
019200735
ADMINISTRATOR:JOSEPH FARRISH IIIFACILITY TYPE:
740
ADDRESS:4639 MALABAR AVETELEPHONE:
(909) 483-2505
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94546
CAPACITY:4CENSUS: 3DATE:
11/22/2023
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Joseph Gapasin, AdministratorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff incorrectly dispensed medications to residents.
Staff falsified resident's records.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) K. Nguyen arrived to conduct visit on the above allegation. LPA met with administrator, Joseph Gapasin, Administrator and discussed the reason for visit.

During investigation LPA interviewed administrator and staff (S1) and reviewed client files. As LPA requested copy of SIR that involved medication error, and print out of the sign off medication tracker (ECP and iServe) documentation replacing MARs (Medication Administration Record's). Facility administrator confirmed they did sign off on the ECP that they giving the medication as prescribe by the PCP to the resident , but the staff forgot to administer the medication to the resident . LA reviewed ECP records indicated that it was signed off by the staff, but on noted that it wasn’t given. LPA gathered copies SIR and verified that the incident was being reported.

Report continue on LIC 9099C...

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2023
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
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
11/16/2023 and conducted by Evaluator Kelly Nguyen
COMPLAINT CONTROL NUMBER: 15-AS-20231116151906

FACILITY NAME:CALIFORNIA MENTOR - MALABAR HOMEFACILITY NUMBER:
019200735
ADMINISTRATOR:JOSEPH FARRISH IIIFACILITY TYPE:
740
ADDRESS:4639 MALABAR AVETELEPHONE:
(909) 483-2505
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94546
CAPACITY:4CENSUS: 3DATE:
11/22/2023
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Joseph Gapasin, AdministratorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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9
Staff did not follow reporting requirements.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) K. Nguyen arrived to conduct visit on the above allegation. LPA met with administrator, Joseph Gapasin, Administrator and discussed the reason for visit.

Allegation: Staff did not follow reporting requirements.

Based on interviewed of administrator and records reviewed. Facility administrator was able to provide proof that all incident that happened are being documented, and are reported.

Based on interviewed conducted, and records reviewed, the above allegations have been found to be UNSUBSTANTIATED. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

Exit interview conducted and a copy of report provided via email PDF.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 15-AS-20231116151906
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: CALIFORNIA MENTOR - MALABAR HOME
FACILITY NUMBER: 019200735
VISIT DATE: 11/22/2023
NARRATIVE
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This agency has completed the investigation alleging facility staff incorrectly dispensed medications to residents. The investigation alleging facility falsified resident’s records. We have found that the complaint is SUBSTANTIATED, meaning the allegation is valid because the preponderance of the evidence standard has been met.

Exit interview is conducted and a copy of this report is provided via email including the LIC 9099D. An appeal rights is provided via email.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 15-AS-20231116151906
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: CALIFORNIA MENTOR - MALABAR HOME
FACILITY NUMBER: 019200735
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/15/2023
Section Cited
CCR
80075(b)
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80075 Health Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.
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Administrator agrees to review the regulation and find an outside vendor to conduct a training for all staff regrading medication, and submit to CCLD by POC date.

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This requirement was not met as evidence by; Based on LPA record review, and interviews ECP electronic records and iServe records shows that medication was not given as precribed by PCP.
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Type B
12/15/2023
Section Cited
CCR
80012(a)
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80012 False Claims
(a) No licensee, officer, or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.
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Adminstraor agrees to find an outside vendor to train all staff on how to properly used the ECP system, and submit a copy of all staff participate sign and dated to CCLP by POC date.
Administrator agrees to do a self-certification for the next two months that he will double check the ECP electronic records to make sure all records are enter correctly and submit to CCLD at the end of every week.
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This requirement was not met as evidence by; Based on LPA record review, and interviews ECP electronic records and iServe records states that medication was not giving to resident, but was checked off as given.
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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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4