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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405800467
Report Date: 04/19/2022
Date Signed: 04/19/2022 04:12:31 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/04/2020 and conducted by Evaluator Darlene Chavez
COMPLAINT CONTROL NUMBER: 29-AS-20200904091704
FACILITY NAME:GARDEN CREEKFACILITY NUMBER:
405800467
ADMINISTRATOR:KIRK P KLOTTHORFACILITY TYPE:
740
ADDRESS:73 BROAD STREETTELEPHONE:
(805) 543-2311
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93405
CAPACITY:72CENSUS: DATE:
04/19/2022
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Lisa Hulse, Vice President of OperationsTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Facility staff did not give medication as prescribed.
INVESTIGATION FINDINGS:
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On 4/19/2022 at 12:45 pm, Licensing Program Analyst (LPA) Chavez initiated an unannounced follow-up complaint investigation visit on the allegation listed above. LPA met with Lisa Hulse, Vice President of Operations, and explained the purpose of the visit.

On the allegation “Facility staff did not give medication as prescribed,” the complainant’s concern was that staff were overmedicating residents. Complainant states that residents were being given larger doses and greater frequency of as-needed medications (PRNs). To investigate the allegation, LPA reviewed records and interviewed staff.

Continued on 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022
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 5
Control Number 29-AS-20200904091704
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: GARDEN CREEK
FACILITY NUMBER: 405800467
VISIT DATE: 04/19/2022
NARRATIVE
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On 4/15/2022 at 12:00 pm, LPA interviewed Staff #1 (S1) who stated that they were aware of an incident where Staff #2 (S2) had given a PRN to Resident #1 (R1), and R1 did not request it.

On 4/19/22 at 2:05 pm, LPA reviewed a document title “Employee Warning Notice” dated 9/09/2020. In the Notice, there were two infractions on medication errors. S2 was noted to “have signed for a medication that was never given” and “Med Error for Carbidopa Levodopa from bubble pack.” Both infractions were in August 2020, and S1 was demoted from Med-Tech to Personal Care Assistant.

Based on evidence obtained, the allegation “Facility staff did not give medication as prescribed,” is deemed Substantiated at this time. S1 was found to have performed medication errors which could have caused injury to residents in care.

Exit interview conducted, deficiency cited, and report and appeal rights emailed to the administrator and VP of Operations.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20200904091704
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GARDEN CREEK
FACILITY NUMBER: 405800467
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/26/2022
Section Cited
HSC
1569.269(a)(6)
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1569.269(a)(6) Enumerated rights; severability. (a)Residents of residential care facilities for the elderly shall have all of the following rights: (6) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
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Administrator demoted S2 on 9/09/2020. Safety training conducted with all staff by 4/26/2022 and a copy of training sign-in sheet sent to CCL.
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Based on interview and record review, the licensee did not comply with the section cited above as residents were not administered their medications as prescribed which poses a potential health and personal rights risk to persons 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: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/04/2020 and conducted by Evaluator Darlene Chavez
COMPLAINT CONTROL NUMBER: 29-AS-20200904091704

FACILITY NAME:GARDEN CREEKFACILITY NUMBER:
405800467
ADMINISTRATOR:KIRK P KLOTTHORFACILITY TYPE:
740
ADDRESS:73 BROAD STREETTELEPHONE:
(805) 543-2311
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93405
CAPACITY:72CENSUS: DATE:
04/19/2022
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Lisa Hulse, Vice President of OperationsTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Facility retains residents who require more care and supervision than is provided by the facility
INVESTIGATION FINDINGS:
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On the allegation “Facility retains residents who require more care and supervision than is provided by the facility,” the complainant’s concern was that the facility retained residents with Dementia. The facility is not licensed for residents with memory care needs. To investigate the allegation, LPA reviewed records and interviewed staff.

On 4/15/2022 from 12:30 pm to 2:30 pm, LPA Chavez reviewed nine physician reports. All nine physician reports reveal that residents did not have diagnosis of Dementia nor Alzheimer’s. LPA reviewed section 14. “Mental Condition” of the reports and only one Resident #2 (R2) had a note stating that R2 is “At times forgetful.”

Continued on 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022
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 5
Control Number 29-AS-20200904091704
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: GARDEN CREEK
FACILITY NUMBER: 405800467
VISIT DATE: 04/19/2022
NARRATIVE
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On 4/15/2022 from 11:48 am to 2:35 pm, LPA interviewed five staff. All five staff stated that when a resident has dementia-like behaviors, staff inform their supervisor, and the resident is tested for a UTI. If the resident does not have a UTI, the resident is assessed by their physician. If physician diagnoses a resident with dementia, management meets with the resident’s family and discusses steps for moving the resident to a facility with a higher level of care.

Based on evidence obtained, the allegation “Facility retains residents who require more care and supervision than is provided by the facility” is deemed Unsubstantiated at this time. Documentation shows the facility is not retaining residents with dementia and staff interviews corroborate the process for ensuring residents with onset dementia are assessed and given the care needed.

Exit interview conducted and report emailed to the administrator and VP of Operations.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5