374602751-9-6-2023-08-AS-DNGN-CVF2YV-20230906174923

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374602751
Report Date: 09/06/2023
Date Signed: 09/06/2023 05:49:46 PM

Document Has Been Signed on 09/06/2023 05:49 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	DEL CERRO MANOR III		FACILITY NUMBER:	374602751
ADMINISTRATOR:	BARTH, BENJAMIN		FACILITY TYPE:	740
ADDRESS:	6655 CRAMPTON COURT		TELEPHONE:	(619) 713-5193
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92119
CAPACITY: 6		CENSUS: 6	DATE:	09/06/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Caregiver Marta Stone and Supervisor Elda Acosta		TIME COMPLETED:	06:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	LPA Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management – Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Marta Stone. LPA then met with Supervisor Elda Acosta, who arrived later during the visit. Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 05/22/2023). According to the LIC624: during the afternoon of 05/19/2023, an error by Staff #1 (S1) led to Resident #1 (R1) receiving doses of multiple medications which were not prescribed to them. [These medications were instead prescribed to Resident #2 (R2)]. [See LIC 811 Confidential Names List for a description of select person identifiers used in this report]. During today’s visit, LPA performed a brief facility tour and welfare check on R1, finding that they were safe, alert, and smiling. LPA also interviewed relevant staff and reviewed pertinent facility and hospital care records. Due to their baseline memory loss, R1 was not able to participate as a reliable historian about the incident. R1’s fellow house mates also had baseline memory loss and could not remember the incident. Per their latest LIC602 Physician’s Report (dated 01/31/2023), R1 was diagnosed with Dementia and required staff assistance with storing and taking their prescribed medications. Staff interview and care records showed: During the 05/19/2023 incident, Staff #2 (S2) was responsible for giving R1 and R2 their respective afternoon medications. Instead of handing R2’s medications directly to R2 and observing them ingest them, S2 instead placed the medications in a labeled cup, then placed the cup on a meal tray. S1 subsequently picked up this meal tray and delivered it to R1 (instead of R2). [CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: DEL CERRO MANOR III	FACILITY NUMBER: 374602751
	VISIT DATE: 09/06/2023

NARRATIVE

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[CONTINUED FROM LIC 809] S1 did not read and verify the name on the cup before handing the tray, with the medicines, to R1. R1 then ingested multiple medications which did not belong to them. S1 and S2 soon recognized the medication error. Although R1 initially did not present any adverse health symptoms, S2 timely arranged for R1 to be transported to a local hospital for observation/evaluation. After arriving at the hospital, R1 displayed drowsiness and slept more than usual.

Hospital discharge paperwork showed: R1 was kept at the hospital from 05/19/2023 through 05/21/2023 following an “accidental overdose.” A hospital physician diagnosed R1 with “toxic encephalopathy” (defined by the National Institutes of Heath as “brain dysfunction caused by toxic exposure”), “sinus of bradycardia with first-degree AV [atrioventricular] block” (defined by the National Institutes of Health as a heart rhythm of “fewer than 60 beats per minute”), “hypotension” (low blood pressure), and “QT prolongation” (an extended interval between the heart contracting and relaxing). The physician attributed the above acute conditions to R1 having taken medications not prescribed to them. By time of R1’s discharge from the hospital on 05/21/2023, hospital records showed their “mental status [was] improving.”

Staff interview further showed: Licensee timely notified R1’s responsible person, primary care physician, and CCLD the same day the incident occurred. Licensee verbally counseled S1 and S2 and discussed the incident with the larger direct care staff team. However, Licensee had no written record/proof of these trainings/discussions. Also, the medication errors which affected R1 on the afternoon 05/19/2023 did not prevent R2 from receiving their respective prescribed medications on that date, and R2 did not ingest any medications belonging to R1.

A preponderance of evidence exists to show that during the incident in question, License’s staff gave R1 medications which were not prescribed to them. The incident caused an adverse health consequence for R1, for which they were kept at a hospital for two (2) nights. One (1) deficiency was thus cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). CCLD determined that the deficiency resulted in resident illness; an immediate civil penalty of $500.00 was thus charged and noted on the LIC421-IM. A Plan of Correction was jointly developed with the Licensee.

An exit interview was conducted with Acosta, to whom a copy of this report, the LIC 809-D, the LIC421-IM, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/06/2023 05:49 PM - It Cannot Be Edited

Created By: Dang Nguyen On 09/06/2023 at 05:20 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: DEL CERRO MANOR III	FACILITY NUMBER: 374602751
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/06/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/07/2023 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care: “(a)(4) The licensee shall assist residents with self-administered medications as needed.” This requirement was not met, as evidenced by:	1 2 3 4 5 6 7	Per licensee, S1 resigned from facility employment around June 2023. Licensee agreed to retrain S2 and all remaining direct care staff on “The Seven Rights of Medication Administration” and licensee’s expectation that the same staff member performs the “Seven Rights” from beginning to end. By the POC due date, Licensee agreed to E-mail LPA the proposed date for the training. No later than 09/30/2023, Licensee agreed to E-mail LPA a copy of the training sign-in sheet as evidence of training completion.
	8 9 10 11 12 13 14	Based on records and interviews, the licensee did not assist 1 of 6 residents (R1) with self-administered medications as needed/prescribed, which posed an immediate health risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Lizzette Tellez

LICENSING EVALUATOR NAME:

Dang Nguyen

LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023

LIC809 (FAS) - (06/04)

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