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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880916
Report Date: 12/28/2022
Date Signed: 12/28/2022 12:15:27 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/20/2022 and conducted by Evaluator Amy Goldenberg
COMPLAINT CONTROL NUMBER: 56-AS-20221220134804
FACILITY NAME:ADVENTURE CARE HOMEFACILITY NUMBER:
331880916
ADMINISTRATOR:CANTORIA, MARIAFACILITY TYPE:
740
ADDRESS:1992 TEMESCAL AVE.,TELEPHONE:
(909) 569-2280
CITY:NORCOSTATE: CAZIP CODE:
92860
CAPACITY:6CENSUS: 4DATE:
12/28/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Angie Zalazar, CaregiverTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Facility staff did not give resident the correct prescribed dosage of medication.
INVESTIGATION FINDINGS:
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This unannounced visit by Amy Goldenberg, Licensing Program Analyst (LPA), is to initiate the 10 day visit to investigate the above-mentioned complaint allegation. LPA met with caregiver Angie Zalazar and discussed the elements of the allegation.

During this investigation visit LPA interviewed staff, reviewed R1's medications, medication records/orders, and Indivual Program Plan. LPA received copies of medication treatment records, and three incident reports dated 10/24/2022, 11/19/2022, 11/24/2022. It is alleged that prior to R1's most recent hospitalization 12/20/2022 it is believed the client was not receiving the correct dosage of medication prescribed. Investigation revealed the following: LPA review of the medications on hand and the medication treatment record show that staff are dispensing medications and signing out each dose. The initials "HP" is signed on the days that R1 has been in the hospital.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2022
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 2
Control Number 56-AS-20221220134804
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: ADVENTURE CARE HOME
FACILITY NUMBER: 331880916
VISIT DATE: 12/28/2022
NARRATIVE
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Medications are dispensed in bubble packs and are numbered. LPA did not find a discrepancy during their review. Interview revealed that R1's medication was changed during their hospitalization and staff maintain that they followed the medication orders that R1 was discharged with. Review of the incidents reports indicate changes in behavior and aggression leading up to hospitalization. Incident report dated 11/24/2022 indicate that on 11/24/2022 a 5150 hold was initiated and that on 11/28/2022 R1 was re-evaluated and diagnosed with dementia.

Based on the available information regarding R1 receiving the correct prescribed dosage of medication, we have found the complaint allegation Unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. A copy of this report is being reviewed with and furnished to the facility representative.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2