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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107206933
Report Date: 01/17/2023
Date Signed: 01/17/2023 01:03:39 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, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/21/2022 and conducted by Evaluator Katie Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20220921094752
FACILITY NAME:VICTORIA'S CARE HOMEFACILITY NUMBER:
107206933
ADMINISTRATOR:GITTI, JOSEPHFACILITY TYPE:
740
ADDRESS:6736 N WESTERN AVETELEPHONE:
(408) 482-6166
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY:6CENSUS: 6DATE:
01/17/2023
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Joseph GittiTIME COMPLETED:
01:20 PM
ALLEGATION(S):
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Staff are not dispensing medications as prescribed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Katie Brown arrived at the facility to conduct a subsequent complaint visit and deliver complaint investigation findings. LPA discussed the elements of the allegations with Administrator Joseph Gitti and Harmeen Jhutti.

Based on record review of R1’s Centrally Stored Medication Log and the Medication Administration Record (MAR) it was not documented that a medication was started once received. Interview reveals that based on these documents, it cannot be confirmed that medication was given. The preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. A deficiency is being cited in accordance with California Code of Regulations on the attached LIC 9099-D.

An exit interview was conducted and plan of correction (poc) was developed. A copy of this report and Appeal Rights were discussed and left with Joseph Gitti, whose signature on this form confirms receipt of these documents.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023
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
Control Number 24-AS-20220921094752
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: VICTORIA'S CARE HOME
FACILITY NUMBER: 107206933
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/25/2023
Section Cited
CCR
87465(c)(2)
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87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the residentf.....shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.
This requirement was not met as evidenced by:
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The facility has implemented an electronic medication documentation system which is now being used to track and document medication.

AD will conduct a staff training on medication documentation and provide proof of training to CCLD by the due date via email.
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Licensee did not ensure that facility staff assisted R1 was medication as perscribed by the physician. Cipro was delivered and entered onto the centrally stored log but not added to the MAR. AD cannot confirm that the medication was started or given to R1 as ordered.
This poses a potential health, safety or personal rights 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.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4