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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604560
Report Date: 06/18/2024
Date Signed: 06/18/2024 01:52:16 PM

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
06/11/2024 and conducted by Evaluator Ramon Serrano
COMPLAINT CONTROL NUMBER: 08-AS-20240611121226
FACILITY NAME:GRACEFUL HEARTS ASSISTED LIVINGFACILITY NUMBER:
374604560
ADMINISTRATOR:ARIDA, JULIAFACILITY TYPE:
740
ADDRESS:888 CREST DRIVETELEPHONE:
(619) 650-4688
CITY:CHULA VISTASTATE: CAZIP CODE:
91910
CAPACITY:6CENSUS: 3DATE:
06/18/2024
UNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Jullia AridaTIME COMPLETED:
02:04 PM
ALLEGATION(S):
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Untrained individual dispensed medication to resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced visit to deliver investigative findings. LPA was granted entry into the facility and met with Administrator Jullia Arida to whom LPA explained the purpose of the visit.

Community Care Licensing (CCL) has investigated the above listed complaint allegation. The investigation consisted of records review and interviews with staff and outside sources.

It was alleged that an untrained individual dispensed medication to Resident 1 (R1) (an LIC 811 Confidential Names List was provided to the facility representative to identify the resident) It was reported that R1's responsible party dispensed medication to R1. Interview with R1's responsible party (RP) revealed that R1 was on end stage hospice care. On June 4, 2024 R1 was having difficulty breathing and per the hospice nurse's instruction RP administered morphine to R1. RP further stated that prior to administering the medication he received training and education regarding R1's hospice "comfort kit."
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024
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-20240611121226
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: GRACEFUL HEARTS ASSISTED LIVING
FACILITY NUMBER: 374604560
VISIT DATE: 06/18/2024
NARRATIVE
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LPA interviewed outside agency (OA) who stated that the facility Administrator does not allow their staff to administer morphine to residents. OA stated that together R1's responsible party, the hospice agency and facility administrator devised a plan for R1's responsible party to administer the morphine to R1. OA stated that teaching was provided and that everyone was in agreement with the plan. OA further stated that they have a "good working relationship" with the facility since they are "not new" and they have worked with them in the past. OA further stated that they have provided various training's to the facility.

LPA interviewed Administrator who stated that facility staff does not administer any form of morphine to the hospice residents. Administrator stated that the normal procedure for end stage hospice is they report symptoms to hospice; then they are instructed which medications to give. If hospice instructs to give morphine to a resident, the facility staff would give the morphine to the trained family member to administer, unless the hospice nurse is present at the facility. Administrator stated that the family had the option to wait for the hospice nurse to arrive or to administer the medication themselves. Administrator stated that on June 4, 2024 she along with R1's responsible party contacted the hospice agency to advise them of R1's symptoms. Hospice nurse authorized R1's responsible party to administer the morphine so that R1 would not have to wait in distress until she arrived at the facility.

LPA reviewed outside agency clinical notes dated June 4, 2024. Clinical notes indicated Hospice nurse met with R1's responsible party and administrator for update. Clinical notes indicated that R1's responsible party administered morphine to R1 one hour prior to RN's arrival. Clinical notes further stated that R1 appeared to be transitioning to end of life care.

Upon thorough investigation, it was determined that R1's responsible party, under the guidance of the hospice agency, administered the medication (morphine) to R1 as per established protocols and instructions provided by the hospice agency.

Based upon the foregoing, the above listed allegation is unsubstantiated. This finding means that the preponderance of the evidence standard has not been met and the allegation is not valid.

An exit interview was conducted with Jullia Arida. A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to Jullia Arida whose signature below verifies receipt of these rights.


SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2