306001102-1-24-2023-22-AS-SSAS-CNLV95-20230131151346

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306001102
Report Date: 01/24/2023
Date Signed: 01/24/2023 12:36:35 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/10/2022 and conducted by Evaluator Patricia Velazquez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20221010092541

FACILITY NAME:	JASMIN'S CARE HOME		FACILITY NUMBER:	306001102
ADMINISTRATOR:	MANUEL G. PEREZ		FACILITY TYPE:	740
ADDRESS:	2817 SAN JUAN LANE		TELEPHONE:	(714) 662-0625
CITY:	COSTA MESA	STATE: CA	ZIP CODE:	92626
CAPACITY:	6	CENSUS: 4	DATE:	01/24/2023
		UNANNOUNCED	TIME BEGAN:	10:46 AM
MET WITH:	Manuel Perez - Administrator		TIME COMPLETED:	12:50 PM

ALLEGATION(S):

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Facility staff member is not giving resident medication according to the label
Facility was not allowing resident to use the commode located in the bathroom

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Patricia Velazquez conducted an unannounced subsequent complaint visit to deliver the findings of the investigation regarding the above allegations. LPA Velazquez was allowed entry into the facility and met with Administrator Manuel Perez.

On today's visit LPA Velazquez conducted interviews with residents and staff. LPA Velazquez also reviewed and obtained copies of facility, resident, and staff records. During the course of the investigation the following was revealed: LPAs Ruth Martinez and Patricia Velazquez conducted interviews with residents and staff. Six of six individuals interviewed could not corroborate the above allegations. LPA Velazquez also reviewed facility, resident, and staff records. The records reviewed included Physician's Reports, Resident Appraisals, Appraisal Needs and Services Plans, Centrally Stored Medication and Destruction Records (CSMDRs), Resident (R) #2's Progress Notes by Mark Abramson, M.D. dated September 27, 2022 at 9:28 AM, and staff training records.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2023

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 22-AS-20221010092541

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: JASMIN'S CARE HOME	FACILITY NUMBER: 306001102
	VISIT DATE: 01/24/2023

NARRATIVE

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Regarding the allegation: Facility staff member is not giving resident medication according to the label the following was revealed: R2's page 7 of 8 Progress Notes by Mark Abramson, M.D. dated September 27, 2022 at 9:28 AM documented Hydrocodone - Acetaminophen (NORCO) 5-325 mg be administered 1 tablet by mouth every 6 hours as needed for severe pain. Two of two individuals interviewed indicated they provided R2 with NORCO medication as prescribed by the doctor and could not corroborate the allegation: Facility staff member is not giving resident medication according to the label. Four of four individuals interviewed stated they received their medications as prescribed by their doctors. Administrator Manuel Perez stated he spoke with R2's doctor and that the doctor stated they would not refill the NORCO prescription for fear resident would become addicted to NORCO. Per Administrator Perez, R2's doctor advised the facility to administer Over The Counter (OTC) Acetaminophen 500 mg for pain whenever possible and to provide the NORCO when resident was experiencing severe pain.

Regarding the allegation: Facility was not allowing resident to use the commode located in the bathroom the following was revealed: Two of two individuals interviewed indicated facility staff provided R2 with a bedside commode to facilitate going to the bathroom especially at night. R2 also indicated that at times it was easier to use the bedside commode than going to the bathroom. R2 currently uses the bathroom whenever they need to use the bathroom and is no longer using a bedside commode. The 2 staff interviewed stated the bedside commode was only utilized when R2 came home from the hospital after R2 underwent surgery for a fractured hip.

Based on the observations made, interviews which were conducted and the records that were reviewed, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the following allegations: Facility staff member is not giving resident medication according to the label and Facility was not allowing resident to use the commode located in the bathroom are deemed UNSUBSTANTIATED.

An exit interview was conducted with Administrator Manuel Perez and a copy of this report along with the LIC 811 was provided at the time of this visit.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2023

LIC9099 (FAS) - (06/04)

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