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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701387
Report Date: 04/10/2025
Date Signed: 04/10/2025 09:40:17 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH 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
12/19/2024 and conducted by Evaluator Vincent Moleski
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20241219080650
FACILITY NAME:FIVE STAR RCFE 1 INCFACILITY NUMBER:
342701387
ADMINISTRATOR:CARIDAD, AMY ROSEFACILITY TYPE:
740
ADDRESS:6512 STAR BIRD CTTELEPHONE:
(916) 271-2075
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:6CENSUS: 4DATE:
04/10/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jayson CaridadTIME COMPLETED:
09:50 AM
ALLEGATION(S):
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Staff are not giving resident medication as needed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with facility administrator Jayson Caridad and explained the purpose of the visit.

This investigation consisted of interviews, observation, and record review. LPA Moleski interviewed Caridad, two additional staff members (S1-S2) and three residents (R1-R3).

In an interview, a resident (R1) said they had not received their painkillers when they asked for them, and sometimes only received one painkiller when they should have received two. LPA Moleski reviewed R1’s file, including their medication administration records (MARs) and centrally stored medication records.

[continued on 9099-C]
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
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 4
Control Number 27-AS-20241219080650
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: FIVE STAR RCFE 1 INC
FACILITY NUMBER: 342701387
VISIT DATE: 04/10/2025
NARRATIVE
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R1 was admitted to this facility on 12/1/24, according to R1’s admission agreement. R1 came to the facility with an order dated 11/25/24 to take one Oxycodone tablet every six hours as needed. Then, R1 received a change order to take one tablet by mouth twice per day dated 12/4/24. However, on 12/10/24, R1's physician changed the order again to be take two tablets every six hours as needed. R1's latest prescription for Oxycodone, dated 12/17/24, indicated that R1 was to take two tablets by mouth every six hours as needed, and one tablet twice daily.

During an audit of R1’s medications on 12/20/24, LPA Moleski observed that R1 had a 60-tablet bottle of Oxycodone, which contained 27 tablets. The bottle was started on 12/5/24, according to R1’s centrally stored medication records. Both routine and PRN doses of the medication were drawn from this same 60-tablet bottle, according to Caridad.

R1's MARs indicate R1 received routine doses of Oxycodone twice on Dec. 5 and 6, and once on Dec. 7, for a total of five doses. R1 visited the hospital later that day and remained hospitalized until Dec. 11. R1 received two routine doses of Oxycodone on Dec. 19, and once on the morning of Dec. 20. R1 received a total of eight daily doses of this medication between his admission date and the date of LPA Moleski’s medication audit on 12/20/24.

R1's PRN MARs show doses of Oxycodone were given on Dec. 2 [1 tablet] Dec. 3. [1 tablet] Dec. 11 [2 tablets], Dec. 13 [1 tablet at 7:30 a.m. and 1 at 8 p.m.], Dec 14. [1 tablet at 8 a.m. and 1 tablet at 9 p.m.], Dec. 15 [an unknown dose at 9 a.m. and an unknown dose at 9 p.m.], Dec. 16 [an unknown dose at 9 a.m. and 2 tablets at 7 p.m.], Dec. 17 [an unknown dose at 9 a.m. and another unknown dose at 8 p.m.], Dec. 18 [an unknown dose at 4:30; a.m. or p.m. not recorded], Dec. 20 [1 tablet]. This totals 9 confirmed tablets were administered from the bottle opened on the 5th, and anywhere between 6 and 12 additional tablets were administered without a recorded dosage, presuming no more than two tablets were given at the intervals recorded. As stated above, R1 had a prescription order on file to take two tablets every six hours as needed, which means R1 should have been able to receive two tablets upon request, rather than one, starting from 12/10/24.

[continued on 9099-C]
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20241219080650
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: FIVE STAR RCFE 1 INC
FACILITY NUMBER: 342701387
VISIT DATE: 04/10/2025
NARRATIVE
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Between the routine and PRN administrations as described above, R1 may have had anywhere between 23 and 29 total tablets administered between 12/5/24 and 12/20/24. This should have left anywhere between 31 and 37 tablets remaining in the bottle. However, there were 27 tablets remaining in the bottle as of 12/20/24.

22 CCR Section 87465(b)-(d) requires that, for any resident receiving PRN medications, there must be a physician’s note on file specifying the resident’s ability to determine their need for PRN medication, and their ability to communicate their symptoms. Licensees are not permitted to assist residents with self-administration of PRN medications without such a note on file and, unless the resident is determined to have no deficits in their ability to determine their own need for medication and their ability to communicate symptoms, licensees are required to maintain accurate records of dates, times, and dosages of all PRN medications given. R1 had no such note on file as of 12/20/24. According to R1’s LIC 602, R1 suffered from mild cognitive impairment, including confusion and disorientation.

The department has determined the following as it relates to the allegation that facility staff are not giving a resident medication as needed:

Based on interview, observation and record review, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met.

This facility is hereby cited per 22 CCR Section 87465(a)(4). An exit interview was held with Caridad. Appeal rights and a copy of this report were left with Caridad.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20241219080650
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: FIVE STAR RCFE 1 INC
FACILITY NUMBER: 342701387
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/11/2025
Section Cited
CCR
87465(a)(4)
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“(4) The licensee shall assist residents with self-administered medications as needed.” This requirement was not met as evidenced by:
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Licensee has already performed staff training regarding medication management. Licensee agrees to send documentation regarding this training to LPA Moleski by POC due date. vincent.moleski@dss.ca.gov
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Based on observation, record review, and interview, R1’s medications were mismanaged by facility staff, which poses an immediate health, safety, and/or personal rights risk.
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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: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4