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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 397005336
Report Date: 12/20/2021
Date Signed: 12/20/2021 04:08:48 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/24/2021 and conducted by Evaluator Arlene D Garcia
COMPLAINT CONTROL NUMBER: 27-AS-20211124082023
FACILITY NAME:RM UGALE CARE HOMEFACILITY NUMBER:
397005336
ADMINISTRATOR:MAGSAYO-UGALE, MAYBELYNFACILITY TYPE:
740
ADDRESS:110 E. MT. DIABLO AVENUETELEPHONE:
(209) 836-5215
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY:6CENSUS: 4DATE:
12/20/2021
UNANNOUNCEDTIME BEGAN:
09:39 AM
MET WITH:Mabelyn Magsayo-Ugale, Administrator.TIME COMPLETED:
12:13 PM
ALLEGATION(S):
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Facility staff did not make medications inaccessible to resident.
Illegal eviction.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Arlene Garcia made an unannounced visit to RM Ugale to deliver the finding of the above allegation. LPA met with Mabelyn Magsayo-Ugale, Administrator.

It was alleged that the facility staff did not make medications inaccessible to resident.

Based on records reviewed and interviews conducted, the resident consumed medications that were in the residents possession when the resident was picked up from the hospital and brought back to the care home. The administrator stated the hospital was did not inform the staff that the resident had medication. The administrator stated the facility did not receive any forms from the placement agency and the hospital. The administrator stated the staff did not have any communication with the discharging nurse and did not confirm diagnosis or any medical follow-up. When the administrator and care staff brought the resident to the residents room, because they were not aware the resident had any medication, the resident was able to attempt to swallow pills which resulted in the facility having to call 911 and bring the resident back to the hospital.

Therefore, the allegation that the facility staff did not make medications inaccessible to resident is substantiated.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arlene D Garcia
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2021
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 3
Control Number 27-AS-20211124082023
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: RM UGALE CARE HOME
FACILITY NUMBER: 397005336
VISIT DATE: 12/20/2021
NARRATIVE
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9099 Cont. >>>>>>>>>>>>>>>>>

Based on records reviewed and interviews conducted, the resident consumed medications that were in the residents possession when the resident was picked up from the hospital and brought back to the care home. The administrator stated the hospital was did not inform the staff that the resident had medication. The administrator stated the facility did not receive any forms from the placement agency and the hospital. The administrator stated the staff did not have any communication with the discharging nurse and did not confirm diagnosis or any medical follow-up. When the administrator and care staff brought the resident to the residents room, because they were not aware the resident had any medication, the resident was able to attempt to swallow pills which resulted in the facility having to call 911 and bring the resident back to the hospital.

Therefore, the allegation that the facility staff did not make medications inaccessible to resident is substantiated.

The following deficiencies was observed (see LIC 9099-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Appeal rights were provided. Exit interview conducted with ED, Teresa Pettapiece and a copy of this report was provided.

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arlene D Garcia
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20211124082023
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: RM UGALE CARE HOME
FACILITY NUMBER: 397005336
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/21/2021
Section Cited
CCR
87465(h)(2)
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87465 Incidental Medical and Dental Care

(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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Licesnee will conduct a training with staff on process when accepting a new resident to ensure all belongings are accounted for and medications are locked. Licesnee will write a letter acknowleding understanding of regulation and submit to LPA by POC date.
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This regulation was not met as evidence by based on the interviews conducted, the licensee did not ensure that resident did not have access to medication. Resident had medication in their purse and attempted to take the medication. This poses an immediate health and safety risks to resident in care.
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Type B
12/29/2021
Section Cited
CCR
87224(b)
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87224 Eviction Procedures
(b) The licensee may, upon obtaining prior written approval from the licensing agency, evict the resident upon three (3) days written notice to quit. The licensing agency may grant approval for the eviction upon a finding of good cause. Good cause exists if the resident is engaging in behavior which is a threat to the mental and/or physical health or safety of himself or to the mental and/or physical health or safety of others in the facility.
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Licesnee will write a letter acknowleding understanding of regulation and submit to LPA by POC date.
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This regulation was not met as evidence by based on the interviews conducted, the licensee did not ensure proper procedures and approval was recieved prior to not accepting the resident back into care. This poses a potential risks to resident 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: Stephenie Doub
LICENSING EVALUATOR NAME: Arlene D Garcia
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3