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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374602406
Report Date: 12/20/2024
Date Signed: 12/20/2024 11:50:38 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/12/2021 and conducted by Evaluator Ryan Fulton
COMPLAINT CONTROL NUMBER: 08-AS-20210312110409
FACILITY NAME:CARLSBAD ELDER CAREFACILITY NUMBER:
374602406
ADMINISTRATOR:JASNA POPOVICHFACILITY TYPE:
740
ADDRESS:1840 BIENVENIDA CIRTELEPHONE:
(760) 729-9800
CITY:CARLSBADSTATE: CAZIP CODE:
92008
CAPACITY:6CENSUS: 4DATE:
12/20/2024
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator Marko KolomijcevTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Licensee did not communicate with resident’s representative of change in medication.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ryan Fulton conducted an unannounced subsequent visit to deliver findings regarding the above allegation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Administrator Marko Kolomijcev. The Department's investigation consisted of LPA observations, interviews with facility staff, residents, and outside sources, as well as records reviews.

It was alleged that Licensee did not communicate with resident’s representative of change in medication. Specifically, it was reported that the Reporting Party had no knowledge of a medication change to R1’s medications list that now included Morphine. Records revealed that R1 was placed on hospice on 02/05/2024. This was confirmed by signatures on the Admissions Consent Agreement by R1’s responsible party. In this agreement, there is documentation describing what care the hospice agency provides, which includes a list of medication prescriptions that will be ordered on behalf of R1. One of the medications listed is Morphine, which comes in two different forms: one is a tab, and the other is liquid.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Ryan Fulton
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024
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 08-AS-20210312110409
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: CARLSBAD ELDER CARE
FACILITY NUMBER: 374602406
VISIT DATE: 12/20/2024
NARRATIVE
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The hospice notes revealed that on 03/01/2024, the hospice agency arrived at the facility to discuss comfort medications with staff and the responsible party. On 03/02/2024, the responsible party requested that the hospice agency begin comfort medications for R1, which included Morphine. On 03/03/2024, it was reported that the responsible party acknowledged that R1 looked comfortable after Morphine had been administered.

Interviews with hospice employees revealed that when an individual is admitted into hospice, they are aware that comfort medications include Morphine. Staff also explained that when an individual is placed on hospice services, the company will order the comfort medication in advance for the client so they will not have to wait for the medication when they begin to decline in health.

This agency has investigated the complaint allegation, Licensee did not communicate with resident's representative of change in medication. The Department has found that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations occurred. Therefore, the above allegations are found to be UNSUBSTANTIATED. An exit interview was conducted, and the report was along with licensee appeal rights (LIC 9058 03/22) were reviewed with Administrator Marko Kolomijcev.
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Ryan Fulton
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2