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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005500
Report Date: 02/03/2023
Date Signed: 02/03/2023 11:46:12 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 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
01/19/2023 and conducted by Evaluator Alvaro Ramirez Jr.
COMPLAINT CONTROL NUMBER: 22-AS-20230119084106
FACILITY NAME:CARE JULIET 1FACILITY NUMBER:
306005500
ADMINISTRATOR:DEL ROSARIO, LESTERFACILITY TYPE:
740
ADDRESS:479 S WELLINGTON RDTELEPHONE:
(209) 914-1153
CITY:ORANGESTATE: CAZIP CODE:
92869
CAPACITY:6CENSUS: 6DATE:
02/03/2023
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Julieta Cervania-Caregiver, Lester A. Del Rosario-AdministratorTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Facility staff mismanaged resident's medications.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Alvaro Ramirez, Jr. and Andrea Mendivil conducted an unannounced complaint visit to deliver findings on the above allegation received on 01/19/23. LPAs were greeted and granted entry into the facility and initially met with caregiver Julieta Cervania. LPAs explained the reason for the visit. Administrator (AD) Lester A. Del Rosario arrrived shortly after.

This agency has investigated the complaint alleging that facility staff mismanaged resident’s medications. LPA Ramirez conducted file reviews and interviews and obtained copies of pertinent documents. Regarding the allegation, the following was revealed: Four of six residents interviewed reported that the facility manages their medication. The remaining two residents interviewed either could not be qualified and/or refused to answer questions. Six of six resident files reviewed indicate that residents are not able to administer their own prescription medications. During the interviews Staff 1 (S1) reported that she is in-charge of passing medications and that she prepares medication for “three days” in advance and places it in “individual closing containers.”
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023
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 3
Control Number 22-AS-20230119084106
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: CARE JULIET 1
FACILITY NUMBER: 306005500
VISIT DATE: 02/03/2023
NARRATIVE
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Per witnesses interviewed, it was reported that Resident 1 (R1) was given pre-poured medications labeled with the wrong time and labeled with another resident’s name. During the initial visit conducted on 01/26/23 LPA Ramirez observed ready to dispense medication in small labeled seven-day plastic pill organizers.

Based on the observations, interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegation: facility staff mismanaged resident’s medications is deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 is being cited on the attached LIC 9099D.



An exit interview was conducted with AD Del Rosario and a copy of this report along with the LIC 811, and the Appeal Rights were provided at the time of this visit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20230119084106
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CARE JULIET 1
FACILITY NUMBER: 306005500
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/06/2023
Section Cited
CCR
87465(h)(5)
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 The following requirements shall apply to medications which are centrally stored: Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as eveidence by:
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 Licensee to conduct in-house training on how to properly manage centrally stored medications. LIcensee to forward POC by 02/06/23.
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Based on observation, Licensee failed to manage medications properly. It was reported that Resident 1 (R1) was given pre-poured medications labeled with the wrong time and labeled with another resident’s name.
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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: Alisa Ortiz
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3