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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374602567
Report Date: 05/25/2021
Date Signed: 05/25/2021 02:55:38 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, 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
05/19/2021 and conducted by Evaluator Adam Hamer
COMPLAINT CONTROL NUMBER: 08-AS-20210519084840
FACILITY NAME:WOODLAND GARDEN RESIDENTIAL CARE IIFACILITY NUMBER:
374602567
ADMINISTRATOR:BENITO ENCABOFACILITY TYPE:
740
ADDRESS:1709 KATY PLACETELEPHONE:
(760) 294-5728
CITY:ESCONDIDOSTATE: CAZIP CODE:
92026
CAPACITY:6CENSUS: 4DATE:
05/25/2021
UNANNOUNCEDTIME BEGAN:
10:02 AM
MET WITH:Benito Encabo, LicenseeTIME COMPLETED:
01:05 PM
ALLEGATION(S):
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Facility did not securely store resident's medications.
Cleaning supplies were accessible to residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Adam Hamer conducted an unannounced complaint investigation visit on today's date. LPA identified himself, spoke with Caregiver Ma Guinto and discussed the purpose of the visit, which was to conduct a complaint investigation visit for the above allegations. Licensee Benito Encabo arrived at the facility later and met with LPA.

The Department’s investigation included LPA observations and interviews with staff and residents. Facility records were also obtained by the Department and reviewed for pertinent evidence.

The Department received a complaint on May 19, 2021 alleging that the facility did not securely store resident's medications and that cleaning supplies were accessible to the residents in care. After arrival at the facilty, LPA observed one (1) resident (R1) who was ambulatory and in the living area adjacent to the kitchen and three (3) residents in their rooms with their doors open (R2, R3 and R4)(see LIC 811 - Confidential Names List). In the kitchen area, medications were stored in an open, unlocked cabinet next to the refrigerator and in a partially open drawer underneath the kitchen counter. In the drawer, there were pills in three (3) unlabeled, open containers; other resident medications in bubble packs and in a bag; and a resident medication in a small, labeled pharmacy container.

Interviews with staff (S1 and S2) revealed that the medicine drawer and cabinet next to the refrigerator were kept open throughout the day and residents' pills were distributed to each resident from the open pill containers. There was no medication administration record at the facility to document what medications were being given to the residents at different times.

With regard to the storage of cleaning supplies, LPA observed several containers of various cleaning supplies underneath the sink in the residents' bathroom, which was unlocked and had no door handle. LPA also observed in the unlocked garage, on top of the washer, bleach and other cleaning supply items and, in an area near the washer, other accessible cleaning supply items. Interviews with S2 revealed that the bathroom door is kept open with a rope and has not had a lock on it for at least a week or so. Interviews with S1 revealed that the door leading to the garage was always propped open with a door stopper, which LPA observed propping the door open when he entered the garage.

Based on the evidence obtained during the complaint investigation, the allegations that facility did not securely store resident's medications and that cleaning supplies were accessible to residents are found to be SUBSTANTIATED, as there is a preponderance of the evidence to prove that the allegations occurred. Citations are being issued in accordance with California Code of Regulations, Title 22, are listed on the LIC9099D, and a plan of correction was developed by the Licensee.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Adam Hamer
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2021
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 08-AS-20210519084840
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: WOODLAND GARDEN RESIDENTIAL CARE II
FACILITY NUMBER: 374602567
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/25/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/25/2021
Section Cited
CCR
87465(h)(2)
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(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
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Licensee Encabo immediately removed the medications from the areas described and stored them in a a locked and inaccessible cabinet in the kitchen area of the facility. Licensee will conduct an in-service training to all staff for medication administration and storage, and provide proof of completion to LPA by June 18, 2021.
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This requirement was not met as evidenced by: Based on LPA observations and staff interviews, the centrally stored medicines were not kept in a safe and locked place and were accessible to resident(s). This posed an immediate health risk to four (4) out of the four (4) residents in care.
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Type A
06/18/2021
Section Cited
CCR
87309(a)
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(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
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Licensee Encabo immediately removed the cleaning supply items from the bathroom and garage, placed them all together in a plastic container, and stored them in the garage, which he locked from the inside of the facility. Mr. Encabo will also conduct an in-service training with staff on proper storage of disinfectants, cleaning solutions and poisons, and provide proof of completion to LPA b June 18, 2021
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This requirement was not met as evidenced by: Based on LPA observation and staff interviews, the Licensee did not ensure that several cleaning supply items in various areas of the facility were inaccessible to residents in care. These items included multiple cleaning supplies under the bathroom sink and in the open, unlocked garage on and near the washing machine. These items posed an immediate safety risk to four (4) out of the four (4) residents in care.
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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: Denise Powell
LICENSING EVALUATOR NAME: Adam Hamer
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2