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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 315002812
Report Date: 05/28/2025
Date Signed: 05/28/2025 11:51:37 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/13/2025 and conducted by Evaluator Cassandra Mikkelson
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20250513102052
FACILITY NAME:BLESSED HOMECARE 2 ROSEVILLEFACILITY NUMBER:
315002812
ADMINISTRATOR:ARGANA, FERDINANDFACILITY TYPE:
740
ADDRESS:4100 SHORTHORN WAYTELEPHONE:
(209) 834-4040
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:6CENSUS: 5DATE:
05/28/2025
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Baby Quintero, AdministratorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff are not ensuring that resident is administered their medications according to physician's instructions.
Staff are mismanaging resident's medications.
INVESTIGATION FINDINGS:
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Licensed Program Analyst (LPA) Cassandra Mikkelson and Licensing Program Manager (LPM) Laura Munoz arrived at the facility unannounced and met with Administrator Baby Quintero to deliver findings for the above complaint allegations.

During the investigation, LPA and LPM conducted interviews, conducted a tour of the facility, and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

*** Report continued on 9099-C***
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025
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 59-AS-20250513102052
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: BLESSED HOMECARE 2 ROSEVILLE
FACILITY NUMBER: 315002812
VISIT DATE: 05/28/2025
NARRATIVE
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Staff are not ensuring that resident is administered their medications according to physician's instructions.

LPA conducted a review of Resident R1’s medication against the Medication List that was provided by home health. LPA observed that R1’s medication list and Medication Administration Record (MAR) do not match and there are medications missing from the medication list that R1 is being given and medications that R1 is prescribed that the facility does not have for R1. During initial investigation on 05/15/2025, LPA requested a medication list for R1’s medications that were being given. Facility could not provide a medication list or Centrally Stored Medication Record (CSMR) to LPA. LPA received medication list from Home health nurse who arrived while LPA was conducting the visit on 05/15/2025.

Interviews with home health nurses that are visiting R1 indicated that their first visit on 05/07/2025, the nurse attempted to review R1’s medications but there were no medications present at the facility for R1. Home health nurse came for a second visit and after their assessment, sent R1 to the hospital due to high blood pressure readings since no medication was being given for blood pressure even though R1 had a current prescription for blood pressure medication. The allegation staff are not ensuring that resident is administered their medications according to physician's instructions is substantiated.

Staff are mismanaging resident's medications.

LPA conducted a review of Resident R1’s medication record. The review of R1’s medications indicated that R1 has five medications on their medication list that are not being given or are not being given as prescribed. During investigation, LPA requested a Centrally Stored Medication Record (CSMR) for R1 but the facility did not have a CSMR for R1.

Based on the information obtained for the allegations above, the allegations are SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Exit interview conducted with Administrator and a copy of the report and appeal rights was provided.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20250513102052
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BLESSED HOMECARE 2 ROSEVILLE
FACILITY NUMBER: 315002812
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/29/2025
Section Cited
CCR
87465(4)
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87465 Incidental Medical and Dental Care (4) The licensee shall assist residents with self-administered medications as needed. This poses an immediate health and safety risk to residents in care.
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Licensee will conduct a medication audit of all resident medications and ensure that Centrally Stored Medication Record is accurate to physician's orders.
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This was not met as evidenced by: records reviewed indicated that medications for Resident R1 were not being dispensed correctly.
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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: Laura Munoz
LICENSING EVALUATOR NAME: Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3