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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604280
Report Date: 05/23/2023
Date Signed: 05/23/2023 09:41:18 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/21/2022 and conducted by Evaluator Tricia Danielson
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220921104338
FACILITY NAME:KELLY'S GREENWAY VILLAFACILITY NUMBER:
374604280
ADMINISTRATOR:GARRETT WELKERFACILITY TYPE:
740
ADDRESS:2133 DREW ROADTELEPHONE:
(619) 442-2576
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY:6CENSUS: 5DATE:
05/23/2023
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Maria Abigail Lacea, CaregiverTIME COMPLETED:
09:45 AM
ALLEGATION(S):
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Staff are not following Physician's orders
Staff did not seek medical attention in a timely manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to conclude an investigation into the allegation listed above. LPA met with Caregiver Maria Abigail Lacea and explained the purpose of the visit.
Regarding the allegation "Staff are not following Physician's orders", it was alleged that facility staff were breaking Resident #1 (R1's) Metformin tablet in half and the request of R1 and without a Physician's order to do so. During the course of this investigation, LPA Danielson interviewed three (3) staff, one (1) resident, and reviewed pertinent documents related to R1. Two (2) of three (3) staff interviewed reported R1's physician changed R1's order for Metformin from 1000mg to 500mg. While awaiting the new prescription's delivery, the staff reported they broke the 1000mg tablet in half to accommodate the new dosage. However, there was no physician's order indicating staff could break the 1000mg tablet in half. Also, LPA review of R1's records did not yield such an order either.
Regarding the allegation "Staff did not seek medical attention in a timely manner", it was alleged that Resident #1 (R1) had not been eating for four (4) to five (5) days and staff did not seek medical attention. LPA Danielson interviewed three (3) staff, one (1) resident, and reviewed pertinent documents related to (CONTINUED ON LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Tricia Danielson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023
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 18-AS-20220921104338
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: KELLY'S GREENWAY VILLA
FACILITY NUMBER: 374604280
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/31/2023
Section Cited
CCR
87465(e)
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Incidental Medical and Dental Care-.a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall ...provide for assistance... with the following:(5)... Assistance with... medications shall be limited to the following:(A) Medications authorized by the person's physician. This requirement was not met as evidenced by:
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The facility will retrain all staff regarding following physician's orders concerning medication administration. Proof of POC to be submitted to CCL by 5/31/2023.
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The licensee did not ensure compliance with medications authorized by a physician. Based on interviews conducted and records reviewed, the facility did not have a physician's order to alter R1's metformin tablet. This poses a potential health, safety, and personal rights risk to 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: Jazmond D Harris
LICENSING EVALUATOR NAME: Tricia Danielson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/21/2022 and conducted by Evaluator Tricia Danielson
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220921104338

FACILITY NAME:KELLY'S GREENWAY VILLAFACILITY NUMBER:
374604280
ADMINISTRATOR:GARRETT WELKERFACILITY TYPE:
740
ADDRESS:2133 DREW ROADTELEPHONE:
(619) 442-2576
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY:6CENSUS: 5DATE:
05/23/2023
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Maria Abigail Lacea, CaregiverTIME COMPLETED:
09:45 AM
ALLEGATION(S):
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9
Staff did not inform resident's responsible party of change in resident's condition
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to conclude an investigation into the allegations listed above. LPA met with Caregiver Maria Abigail Lacea and explained the purpose of the visit.
Regarding the allegation "Staff did not inform resident's responsible party of change in resident's condition", it was alleged that facility staff did not inform Resident #1 (R1's) responsible party of a fall which occurred on April 18, 2022 or that resident had not eaten over the course of four (4) to five (5) days. LPA Danielson interviewed three (3) staff, one (1) resident, and reviewed pertinent documents related to R1. Two (2) of three (3) staff interviewed confirmed R1 did experience a fall on April 18, 2022. Both staff reported R1's responsible party was notified. The third staff interviewed reported R1's responsible party was notified during a visit to the facility.
Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted and a copy of this report was provided along with LIC811- Confidential Names list.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Tricia Danielson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 18-AS-20220921104338
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: KELLY'S GREENWAY VILLA
FACILITY NUMBER: 374604280
VISIT DATE: 05/23/2023
NARRATIVE
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(CONTINUED FROM LIC9099)
R1. Three (3) of three (3) staff interviewed reported R1 did display a drop in appetite. Two (2) staff interviewed reported the drop in appetite occurred over the course of the months of July 2022 and August 2022. One (1) staff interviewed reported R1 lost their appetite after becoming nauseous due to a newly prescribed medication at the end of August 2022. Records reviewed for R1 did not yield evidence of a physician being notified of the loss of appetite.
Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099 D. An exit interview was conducted and a copy of this report was provided along with LIC811- Confidential Names list and Appeal Rights.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Tricia Danielson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4