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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700585
Report Date: 05/20/2021
Date Signed: 05/20/2021 04:00:14 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/19/2021 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20210519170840
FACILITY NAME:INDOCARE HOUSE 2FACILITY NUMBER:
342700585
ADMINISTRATOR:LOMENDEHE, PAULFACILITY TYPE:
740
ADDRESS:8604 BANFF VISTA DRTELEPHONE:
(916) 686-1253
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 5DATE:
05/20/2021
UNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Paul LomendeheTIME COMPLETED:
03:51 PM
ALLEGATION(S):
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Facility did not ensure resident's medication were filled
Resident's medication list is inaccurate
Facility not administering medications as prescribed
INVESTIGATION FINDINGS:
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LPA Michael Bilger arrived unannounced at facility at 2:55pm to open a complaint for the above allegations. LPA requested the following documents from R1: Copy of recent centrally storage medication list, copy of most recent 602, and most recent medication orders. LPA reviewed documents and interviewed Administrator as well as S1 and S2. R1 is currently in the hospital. According to Administrator, all medication with the exception of the prescribed psych meds for R1 was not transferred from one pharmacy to a new pharmacy resulting in medication, including Metformin (diabetic medication) not being given since 3/25/21. Administrator acknowledged the medication error of R1 not receiving medication upon speaking with R1s conservator on 5/19/21. Administrator further acknowledged that S1 and S2 were not giving the medication as prescribed. S1 and S2 further acknowledged that medications were not given since 3/25/21 during their interviews. Medication training for S1 and S2 is current. Based on the findings during this visit and through record review, there is a preponderance of evidence to conclude that R1 did not receive medication as prescribed since 3/25/21, therefore, this allegation is SUBSTANTIATED. Deficiencies were cited today under Title 22 regulations, Division 8. A copy of this report and appeal rights was left with Administrator.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2021
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 27-AS-20210519170840
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: INDOCARE HOUSE 2
FACILITY NUMBER: 342700585
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/21/2021
Section Cited
CCR
87465(a)(5)
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The licensee shall assist residents with self-administered medications as needed. The requirement is not met as evidenced by:
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Licensee will submit a plan to audit medication records weekly to ensure timely and accurate dispensing of medications as prescribed for all residents in care. Weekly audit sheets for the next 4 weeks to be submitted to LPA beginning on POC due date

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Based on record revew and interviews, licensee did not ensure that R1 received medications as prescribed since 3/25/21. This poses an immediate health and safety risk to residents in care.
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Licensee will conduct medication training to staff addressing medication orders and importance of 6 rights of medication. Proof of scheduled training to be submitted to LPA by POC due date.
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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: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2