Complaint Investigation Report

079201161-4-4-2023-15-AS-KHOS-CR8MHH-20230425093735

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CCLD Regional Office , 1515 CLAY STREET, STE. 310

This is an official report of an unannounced visit/investigation of a complaint received in our office on

03/29/2023 and conducted by Evaluator James Sampair

COMPLAINT CONTROL NUMBER: 15-AS-20230329133115

Staff did not ensure that resident's medication were stored in the container they were originally received in.

On 04/04/2023 at 10:00 AM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to inspect facility concerning the allegation above. LPA explained purpose of the visit to Caregiver Nestor Avecilla who then reported the allegation to the Licensee Asha Jain by phone.

At 10:45 AM, Staff S3 opened the locked medication cabinet for LPA who confirmed that the medications were not being stored in their original container, a practice confirmed by staff S1, S2, and S3. Based on staff interview and LPA observation, the preponderance of evidence standard has been met; therefore, the above allegation has been found to be SUBSTANTIATED.

Deficiency cited per Title 22 California Code of Regulations is listed on the LIC9099-D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided via email.