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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604478
Report Date: 04/25/2024
Date Signed: 04/25/2024 12:49:19 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
07/01/2022 and conducted by Evaluator Dang Nguyen
COMPLAINT CONTROL NUMBER: 08-AS-20220701160009
FACILITY NAME:SOUTH PACIFIC VILLAFACILITY NUMBER:
374604478
ADMINISTRATOR:PRONOVOST, SHANELFACILITY TYPE:
740
ADDRESS:543 GUIDERO WAYTELEPHONE:
(916) 768-6948
CITY:ENCINITASSTATE: CAZIP CODE:
92024
CAPACITY:6CENSUS: 6DATE:
04/25/2024
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Caregiver Alfred RiosaTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Licensee centrally stored an expired resident medication.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced subsequent visit to deliver a finding regarding the above prior complaint allegation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Alfred Riosa.

The Complainant alleged that Licensee maintained in its locked central storage (where it keeps medications which are intended to be given to residents) a medication which was beyond its expiration date. CCLD’s investigation involved unannounced facility tours / welfare checks. LPA also reviewed pertinent care records and interviewed relevant staff, residents, and outside sources.


[CONTINUED ON LIC 9099-C]
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
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 3
Control Number 08-AS-20220701160009
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: SOUTH PACIFIC VILLA
FACILITY NUMBER: 374604478
VISIT DATE: 04/25/2024
NARRATIVE
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[CONTINUED FROM LIC 9099]

During a 07/22/2022 site visit, LPA, accompanied by staff, inspected the centrally stored medications and their packaging, which Licensee kept on hand and secured for residents. Of the six residents in care, LPA observed that two residents [Resident #1 (R1) and Resident #2 (R2) had at least one expired medication in Licensee’s central storage. Specifically: R1 had an unopened blister pack/card of as-needed (PRN) tablets which had expired in January 2022. R2 had an opened bottle of PRN tablets which had expired in February 2022. During LPA’s visit, staff confirmed that the medications in question were expired, and removed them from central storage (in preparation for discarding and ordering of replacements).

Based interviews and LPA observation, a preponderance of evidence existed to show that Licensee centrally-stored an expired resident medication. The allegation was therefore Substantiated. One deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D page). A Plan of Correction was jointly developed with the Licensee.

An exit interview was conducted with Riosa, to whom a copy of this report, the LIC 9099-D, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20220701160009
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: SOUTH PACIFIC VILLA
FACILITY NUMBER: 374604478
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/25/2024
Section Cited
CCR
87465(h)(4)
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87465 Incidental Medical and Dental Care: “(h)(4) All centrally stored medications shall be…maintained in compliance with state and federal laws.” This requirement was not met, as evidenced by:
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During LPA’s 07/22/2022 site visit, staff confirmed that the medications in question were expired, and removed them from central storage (in preparation for discarding and ordering of replacements). This resolved the immediate risk. Licensee agreed to retrain its staff to self-audit centrally stored medications, at least monthly, to remove and reorder medications which are about to expire. Licensee agreed to submit the training sign-in sheet to LPA, by the POC due date.
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Based on interview and LPA observation, Licensee did not ensure that all centrally stored medications were maintained in compliance with state and/or federal laws. This posed a potential health and safety risk to 2 of 6 residents (R1 and R2) 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: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3