COMPLAINT FORM D PRIORITY 10-0500 · Type of Investigation: DEATH INVESTIGATION Type of Program:...

State of California-Health and Human Services Agency ADP 7350, Revised 4/09

COMPLAINT FORM This form is intended to document complaints received.

Reported DIn Person D By Letter or E-mail

D By FAX D By Phone

Complainant Name:

Address:

City:

Telephone Number(s):

E-mail:

Complainant's Relationship to Provide

C1 -Facility Resident(s) C2- Facility Staff C3- Neighbors C4- Relative/Friend C5- Public/Gov. Agency C6 - Anonymous C7 -Former Resident C8 - Former Staff C9- Other *** -Unknown

Complaint Number: 10-0500

Department of Alcohol and Drug Programs Licensing and Certification Division

1700 K Street, Sacramento, CA 95811 TDD (916) 445-1942, Fax (916) 322-2658

(916)322-2911

D PRIORITY

Type of Investigation: DEATH INVESTIGATION

Type of Program: LIC/CERT

Provider License Number (If Applicable): 490009CN

Provider Legal Name: Narconon of Northern California

Facility Name: Narconon of Northern California

Address(s}: 262 Gaffey Road

City: Watsonville Zip: 95076

County: Santa Cruz

Contact Name: Jeff Panelli

Telephone Number: (831) 768-7190

Complainant waives confidentiality of his/her name and name of any person named in complaint except provider clients. DYES 0No

COMPLAINT RECORDED BY: M. Vasquez DATE RECEIVED: 08/12/2010

COMPLETE FOR COUNSELOR MISCONDUCT COMPLAINTS

COUNSELOR NAME CERTIFYING ORGANIZATION CERTIFICATION OR EXPIRATION OR REGISTRATION NO. RENEWAL DATE

COUNSELOR COMPLAINT (90-DAY) DUE DATE:

ALLEGATION NATURE OF COMPLAINT (REGULATION I STANDARD)

10561(b)(1)(A) A· .::lient was enrolled in the program on J. Client died on on

I - ----

t the hospital due to < ...

ASSIGNMENT INFORMATION 4

ASSIGNED FIELD OPERATIONS ANALYST: Marie Montiero-Gomez DATE COMPLAINT ASSIGNED: 11/6/2011 (to Alatorre)

ASSIGNED COMPLAINT INVESTIGATOR: -J-:-B~parks- \ '( (\j~f.::+Qn(f~ b DATE INVESTIGATION WAS INITIATED: 11/6/2011 L' t'l )

1\. 1-\ \_C\ Cy(0

INVESTIGATION FINDINGS

ALLEGATION

(REGULATION I STANDARD) RESULT CLASS

ALLEGATION


1.10561 (b)(1)(A) SUBSTANTIATED A 6. 10567(a} SUBSTANTIATED B

2. 10561 (b)(1)(A} SUBSTANTIATED A 7.13010(a}/10563 SUBSTANTIATED B

3. 12055/12050/10563 SUBSTANTIATED A 8.10564 (c) (1} SUBSTANTIATED c

4. 10510 SUBSTANTIATED B

5.10569 SUBSTANTIATED A

COUNSELOR MISCONDUCT COMPLAINT FINDINGS

ALLEGATION RESULT ORDER

FOLLOW-UP INVESTIGATION

RECOMMENDED CATEGORY OF FOLLOW-UP:

FOLLOW-UP VIOLATION (S) RESULTS CLASS FOLLOW-UP VIOLATION (S) RESULTS CLASS

CLOSURE INFORMATION

INVESTIGATION COMPLETED BY: i' " I \ DATE OF INITIAL SITE VISIT: 11/7/2011 and 11/8/2011 f--\ J-\' (\ -- '\ •.! 0 \c-1-U \<:.J

DATE REVIEW WAS COMPLETED: 12/16/2011 DATE OF FINAL REPORT: 2/22/2012

TOTAL FINES ASSESSED: N/A DATE CLOSED: 3/30/2012

COMMENTS

*Notice to complainant of findings went out pursuant to CCR 1 0543(1).

\~N§SUQATING ANAL YST~~G~~ TURE.;. DATE: SUPERVISOR'~ ~ ,~: ";} I ! (ZKl . I [ il;/ I / 3/30/2012 /~~ g,c ,12__, \ i,

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State of California-Health and Human Services Agency ADP 7350, Revised 4/09

COMPLAINT FORM This form is intended to document complaints received.

Reported 0 In Person 0 By Letter or E-mail

D By FAX ~By Phone

Complainant Name:

Address:

City:

Teleohone Number(s):

E-mail:

Complainant's Relationship to Provider:

C1- Facility Resident(s) C2 - Facility Staff C3- Neighbors C4- Relative/Friend C5 - Public/Gov. Agency C6- Anonymous C7- Former Resident C8 - Former Staff C9- Other *** -Unknown

/ /; / ( !A (_/{ c h.-/, ----

Complaint Number: 10-2570



(916) 322-2911

~PRIORITY

Type of Investigation: DEATH INVESTIGATION

Type of Program: LIC ONLY

Provider License Number (If Applicable): 090018AN

Provider Legal Name: NARCONON of Northern California

Facility Name: NARCONON- Vista Bay

Address( s ): 1364 Ruth Haven Lane

City: Placerville Zip: 95667

County:

Contact Name: Daniel Manson

Telephone Number: (530) 295-5550

Complainant waives confidentiality of his/her name and name of any person named in complaint except provider clients. DYES ~NO

COMPLAINT RECORDED BY: J. lto-Orille DATE RECEIVED: February 25, 2011

COMPLETE FOR COUNSELOR MISCONDUCT COMPLAINTS

COUNSELOR NAME CERTIFYING ORGANIZATION CERTIFICATION OR EXPIRATION OR REGISTRATION NO. RENEWAL DATE

COUNSELOR COMPLAINT (90-DAY) DUE DATE:

ALLEGATION NATURE OF COMPLAINT (REGULATION I STANDARD)

Complainant's ' was a client at the facility in r Client

10561(b)(1)(A) went into the hospital in after being in the hospital for about Complainant feels that death occurrecfoe"Ciwse of the treatment at the facility. Complainant stated that ' is concerned that the practices of the sauna treatment.

- ./

\ -- ~-

ASSIGNMENT INFORMATION '

/) . ( ; ( ASSIGNED FIELD OPERATIONS ANALYST: Michael Allen DATE COMPLAINT ASSIGNED: J ( \ l (;_ L}ft1V~ \

ASSIGNED COMPLAINT INVESTIGATOR: DATE INVESTIGATION WAS INITIATED:

INVESTIGATION FINDINGS I I

ALLEGATION


ALLEGATION


COUNSELOR MISCONDUCT COMPLAINT FINDINGS

ALLEGATION RESULT ORDER

FOLLOW-UP INVESTIGATION

RECOMMENDED CATEGORY OF FOLLOW-UP:

FOLLOW-UP VIOLATION (S) RESULTS CLASS FOLLOW-UP VIOLATION (S) RESULTS CLASS

CLOSURE INFORMATION

INVESTIGATION COMPLETED BY: DATE OF INITIAL SITE VISIT:

DATE REVIEW WAS COMPLETED: DATE OF FINAL REPORT:

TOTAL FINES ASSESSED: DATE CLOSED:

COMMENTS

INVESTIGATING ANALYST'S SIGNATURE DATE: SUPERVISOR'S SIGNATURE: DATE:

Page 2 of 2

STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY

DEPARTMENT OF ALCOHOL AND DRUG PROGRAMS 1700 K STREET SACRAMENTO, CA 95811-4037 TTY/TDD (800) 735-2929 (916) 322-2911

Dear'

RE: Complaint Number 1 0-050D/1 0-257D

EDMUND G. BROWN JR .. Governor

This is in response to your correspondence of - , Narconon of Northern California, located at 262 Gaffey Road, Watsonville, CA 95076.

The Department of Alcohol and Drug Programs (ADP) conducted an investigation of the allegations you submitted and determined the outcome, as follows:

• Licensee did not notify the Department of Alcohol and Drug Programs of Decedent's death until one year after the death of Decedent- ADP has substantiated this issue

• Licensee did not send a report of the death of Decedent until one year after Decedent's death- ADP has substantiated this issue

• Licensee did not possess policies and procedures ensuring Decedent sought timely medical treatment- ADP has substantiated this issue

• Licensee provided an inaccurate statement to the Department of Alcohol and Drug Programs- ADP has substantiated this issue

• Licensee did not ensure Decedent was afforded safe, healthful and comfortable accommodations to meet Decedent's needs- ADP has substantiated this issue

• Licensee staff did not complete the required Resident Health Screening for Decedent- ADP has substantiated this issue

• Licensee did not ensure its counseling staff was licensed, certified, or registered six months from date of hire- ADP has substantiated this issue

• Licensee failed to ensure personnel are tested for Tuberculosis annually- ADP has substantiated this issue

flex~·· "0llT ., lPom DO YOUR PART TO HELP CALIFORNIA SAVE ENERGY

For energy saving tips, visit the Flex Your Power website at http://www. fvpower.org

Norma Resnick March 30, 2012 Page 2

Please be assured that ADP monitors facilities/counselors frequently to ensure they maintain compliance with residential and outpatient alcohol and/or drug facility laws, regulations, and standards.

Thank you for bringing your concerns to our attention. If you have any questions, please contact me at (916) 445-9153 or at [email protected].

~incerely,

i \ ['

~.·.! f'01· ~ < ~~~) . ·# .,./ ., :~i ~./\ i \~:z('~AL I . ;~~ Complaint Analyst 0 Program Compliance Branch Licensing and Certification Division

STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY

DEPARTMENT OF ALCOHOL AND DRUG PROGRAMS 1700 K STREET SACRAMENTO, CA 95811 TOO (916) 445-1942 (916) 322-2911

March 30, 2012

Daniel Mason, Director Nathan Tuddenham, Director of Administration Narconon of Northern California 262 Gaffey Road Watsonville, CA 95076

Dear Mr. Manson and Mr. Tuddenham:

NOTICE OF CLEARED DEFICIENCY -INVESTIGATION 10-050D

EDMUND G. BROWN. JR. Governor

The corrections you submitted were received on March 21,2012 and March 1, 2012 for Narconon of Northern California, located at 262 Gaffey Road, Watsonville, California 95076, as noted on the Notice of Deficiency dated February 22, 2012. The corrections have been reviewed and approved as submitted.

Thank you for your cooperation in this matter. If you have any questions, please contact me at (916) 445-9153 or email me at [email protected].

Regards, r'\.

~~ ~~~\'· (} I 1\~ \ J.rv l / a/'~ 'A-ISR ANNA A. ALA TORR • Complaint Investigator Program Compliance Branch Licensing and Certification Division

DO YOUR PART To HELP CALIFORNIA SAVE ENERGY

For energy saving tips, visit the Flex Your Power website at http://W#W.flexyourpower.ca.gov

STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY ADP 6015l, Revised 01/08



(916) 322-2911

PROGRAM INVESTIGATIVE REPORT PROGRAM/FACILITY ID NUMBER: I PROGRAM/FACILITY NAME: I COMPLAINT INVESTIGATION NUMBER: 440009CN Narconon of Northern California 10-0500 REFERENCES: (1) Health and Safety Code Section 11834.01 and California Code of Regulations (CCR), Title 9, Section 10502. Departmental Authority to License.

(2) Health and Human Services Agency, Department of Alcohol and Drug Programs, Alcohol and/or Other Drug Program Certification Standards.

CA Alatorre spoke with SDA Tuddenham concerning the purpose of the visit. SDA Tuddenham described the operations of the program, staff positions, and the services provided to Licensee's client and residents.

CA Alatorre conducted staff and resident interviews for the purpose of this investigation. CA Alatorre also requested and received medical records and documentation probative to the findings of this investigation. The California Department of Alcohol and Drug Programs maintains a copy of all documents referenced as the basis of a deficiency for the purposes of due process of law and other requirements as provided by statute.

Overview Licensee admitted Resident#1 (Hereinafter "Decedent") to Licensee's residential treatment program on

. Decedent's first complaint of .... ·-_ occurred on · On ~

Decedent requested to be transported to the emergency room where Nas admitted. On Decedent expired at the '

~ .. __ ., , a certificate of death was signed by Dr. Steven Smith, M.D. The cause of death was declared by Dr. Steven Smith, M.D. as . _ which occurred

3 prior to Decedent's expiration. Dr. Steven Smith, M.D. further noted that the Decedent suffered Decedent's expiration.

Detailed Chronological Manifest of Decedent's Illness On . a progress note was made my staff member (nursing assistant), Emma Thomas. Emma Thomas indicated that Decedent had

". Decedent's temperature was recorded at

CA Alatorre did not locate a progress note for Decedent for

On at 1 0:30AM, Emma Thomas documented in Decedent's residential chart, ' · --. Decedent's temperature was recorded at A - .

further notation was made "

OnJ 1 at 2:20 p.m. Emma Thomas documented in Decedent's residential chart, r_ . l_ ' _" _

CA Alatorre did not locate a progress not for Decedent for the recheck that was to occur on the evening of

On ___ J Jime not specified), Emma Thomas documented in Decedent's residential chart, llwas doing • · · · · · _ Decedent's temperature was recorded at Emma Thomas further records, {(Will re-check in the PM".

I HAVE READ AND UNDERSTAND THE ABOVE INFORMATION. PLEASE INITIAL HERE:----------

Program/Facility Representative

PAGE:

3 of 18

NAR~ON" NORTHERN CALIFORNIA

262 Gaffey Rd. • Watsonville, CA 95076 • 800.556.8885 • \NWw.drugrehab.net

Date: 19 March 2012

Adrianna Alatorre Complaint Investigator- Program Compliance Branch Department of Alcohol and Drug Programs 1700 K Street Sacramento, CA 95811-4037

Dear Ms. Alatorre,

Enclosed is the response for correction of deficiencies found in investigation 10-050D, findings #4, 6, 7 and 8, investigation 10-059, allegation (b), and investigation 11-030 allegation (a) and findings #1 and 2 for Narconon ofNorthern California, facility license number: 440009CN. Below is an itemized explanation for each correction.

1 0-050D, findings #4 "Licensee provided and inaccurate statement to the Department of Alcohol and Drug Programs. "

I have written an order and dispatched it to all employees who might prepare an Unusual Incident/Injury/Death Report Form. This order details the specific steps for preparing the form in an accurate manner.

1 0-0SOD, finding #6 "Licensee staff did not complete the required Resident Health Screening for Decedent. "

I have written an order and dispatched it to all employees involved with admissions or re-admissions clarifying what paperwork is to be filled out each time a client is transferred or re-admitted.

1 0-050D, findings #7 "Licensee did not ensure its counseling staff was licensed, certified, or registered within six months from date of hire. " and #8 "Licensee failed to ensure personnel are tested for Tuberculosis annually. "

I have written a policy regarding the personnel calendar, what it should contain, and when reminders need to be set up to ensure that no required actions are missed.

11-030, allegation (a) "Licensee transferred Resident #Ito an unlicensed residential facility when personnel opined Resident #1 required 1 - t services.

Attached is an updated referral policy with a more comprehensive explanation of referral criteria and what type of referrals we are responsible for. I have also attached referral lists ensuring that we have appropriate resources available for

©2005 Narconon of Northern California. All rights reserved. Narconon and the Narconon logo are trademarks and service marks owned by the Association for Better Living and education International and are used with its pemrission.

program participants. This policy has been dispatched to all staff and is given to all program participants.

11-030, findings # 1 "Licensee did not produce Resident# I 's treatment file for inspection to California Department of Alcohol and Drug Programs staff" And #2 "Licensee provided an inaccurate statement to the Department of Alcohol and Drug Programs. "

The reason the file was not initially located and why an inaccurate statement was made is because our storage for archived files was too full and had become disorganized. We have since purchased an additional 10' x 40' storage container to house archived files. We have re-organized all of our files, by year, alphabetically and with master lists, to ensure that files are easily found and well organized.

10-059, allegation (b) "Licensee's program discharged Resident #I for reasons not specified in Resident# I 's admission agreement. "

I have modified our Client Rules and Responsibilities in our Admissions Agreement to reflect the reasons why Resident #1 was discharged. The modification can be found under Level III Offenses, point # 15.

Please contact me if you have any questions regarding the above corrections.

Respectfully,

Nathan Tuddenham RAS Senior Director for Administration Narconon ofNorthern California (831) 740-4629 [email protected]

©2005 Narconon oi Northern Caliiorn1a. All rights reserJed. Narconon and tt·,e Narconon logo are trademarks and service marks owned by the Association for Better Living and education International and are used with its permission.

STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY ADP 6015L, Revised 01/08



(916) 322-2911

PROGRAM INVESTIGATIVE REPORT PROGRAM/FACILITY ID NUMBER: 1 PROGRAM/FACILITY NAME: I COMPLAINT INVESTIGATION NUMBER: 440009CN Narconon of Northern California 10-0500 REFERENCES: (1) Health and Safety Code Section 11834.01 and California Code of Regulations (CCR), Title 9, Section 10502. Departmental Authority to License.


FINDINGS

THE FOLLOWING DEFICIENCY{IES) WERE IDENTIFIED AND SUBSTANTIATED DURING THE COURSE OF ~LAS_S __

1

THE INVESTIGATION: :

1. Licensee did not notify the Department of Alcohol and Drug Programs of Decedent's A 91' death until one year after the death of Decedent.

i 2. Licensee did not send a report of the death of Decedent until one year after Decedent's A (!''

death. d~ 3. Licensee did not possess policies and procedures ensuring Decedent sought timely A f)· medical treatment.

!

4. Licensee provided an inaccurate statement to the Department of Alcohol and Drug B ~l Programs. J

: Licensee did not ensure Decedent was afforded safe, healthful and comfortable i

5. accommodations to meet Decedent's needs.

A C:

6. Licensee staff did not complete the required Resident Health Screening for Decedent B 3J 7. Licensee did not ensure its counseling staff was licensed, certified, or registered six

B~H months from date of hire. 0.

I I

8. Licensee failed to ensure personnel are tested for Tuberculosis annually.

INVESTIGATIVE SUMMARY

83\1' '!: 9 /,/6

{lQAJJI-tiJ~J Investigative Procedure •/V:: Complaint Analyst (Hereinafter "CA Alatorre") made an unannounced investigative visit to Narconon of 0-i Northern California ("Licensee") at the above address to investigate death investigation number 1 0-084D " and complaint numbers 10-030, 10-059, 10-152, and 11-030 on November 7, 2011 and November 8, 2011, respectively.

Upon arrival at the Licensee's address, CA Alatorre presented Licensee's Senior Director of Administration, Nathan Tuddenham (Hereinafter "SDA Tuddenham"), with a signed Notice of Inspection of Confidential Records and a signed Notice of Retention of Confidential Records. CA Alatorre requested that the documents be dually signed by the Executive Director or designee and requested copies of the two aforesaid documents. SDA Tuddenham returned an executed copy of the Notice of Inspection of Confidential Records and an executed copy of the Notice of Retention of Confidential Records. CA Alatorre subsequently requested a walk-through of the facility. SDA Tuddenham led CA Alatorre on a walkthrough of the facility. CA Alatorre inspected Licensee's resident rooms, medication room, saunas, recreational facilities, and locations wherein group therapy and one and one therapy are held. Licensee's facility was free of debris and clutter, items were stored neatly, and program participant file cabinets were locked.

I HAVE READ AND UNDERSTAND THE ABOVE INFORMATION. PLEASE INITIAL HERE:----------


PAGE:

2 of 18

STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY ADP 6015L. Revised 02108

PROGRAM INVESTIGATIVE REPORT


1700 K Street. Sacramento. CA 95811 TDD (916) 445-1942, Fax (916) 322-2658

(916) 322-2911

PROGRAM/FACILITY ID NUMBER: I PROGRAM/FACILITY NAME: I COMPLAINT INVESTIGATION NUMBER: 440009CN Narconon of Northern California 10-0500

REFERENCES (1) Health and Safety Code Section 11834.01 and California Code of Regulations (CCR), Title 9, Section 10502. Departmental Authority to License. (2) Health and Human Services Agency, Department of Alcohol and Drug Programs, Alcohol and/or Other Drug Program Certification Standards.

PROGRAM/FACILITY LEGAL NAME: DATE OF SITE VISIT:

Nacronon of Northern California November 7, 2011 and November 8, 2011

ADDRESS (Street, City and Zip):

262 Gaffey Road, Watsonville, CA 95076

TYPE OF INVESTIGATION:

D COMPLAINT D FOLLOW-UP

0 UNLICENSED ~DEATH

TYPE OF PROGRAM/FACILITY: (Please check all that applies)

~ RESIDENTIAL 0 NONRESIDENTIAL

~ AOD LICENSED D DMC CERTIFIED

D DETOXIFICATION

D ADOLESCENT

D NTP D DUI

D PERINATAL

0 COUNSELOR MISCONDUCT- The Counselor Investigative Report may be referred upon.

~ AOD CERTIFIED 0 COUNTY OPERATED 0 CDCR AFTER CARE PROGRAM

THE FOLLOWING INVESTIGATIVE REPORT IS BEING ISSUED AS A RESULT OF THE INVESTIGATION:

D NO DEFICIENCY (Licensed and/or Certified Programs)

~DEATH INVESTIGATION (Licensed and/or Certified Programs)

~CERTIFICATION (AOD Certified Programs)

~NOTICE OF DEFICIENCY (Licensed Programs)

0 NOTICE OF OPERATION IN VIOLATION OF LAW (Unlicensed Programs)

D~TERDEPARTMENTALREFERRAL

The investigation was conducted in accordance with California Code of Regulations (CCR), Title 9, Chapter 5, and/or the Alcohol and/or Other Drug

Program Certification Standards which may include the following: inspeCtion of the program premises, review of program policies, procedures,

staff and resident file{s), and the interview of residents and staff. In addition, the complaint investigator shall notify the licensed and/or certified

program/facility director or his/her designee of the allegation(s) during the exit conference. (The ADP 9080, Detail Supportive Information form and

ADP 7025, Confidential Names form may be referred upon.)

ATE

TELEPHONE: (916)327 -5693

I HAVE READ THE PROGRAM INVESTIGATIVE REPORT AND I UNDERSTAND MY APPEAL RIGHTS.

PROGRAM/,FACILITY REPRESENTATIVE Please sign above, initial any following pages and return the original to AOP.

TELEPHONE NUMBER:

STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY ADP 6015L, Revised 01108



(916) 322-2911



FINDINGS

r THE FOLLOWING DEFICIENCY(IES) WERE IDENTIFIED AND SUBSTANTIATED DURING THE COURSE OF CLASS

THE INVESTIGATION:

Licensee did not notify the Department of Alcohol and Drug Programs of Decedent's 1. A death until one year after the death of Decedent.

2. Licensee did not send a report of the death of Decedent until one year after Decedent's A death.

' 3. Licensee did not possess policies and procedures ensuring Decedent sought timely A medical treatment. Licensee provided an inaccurate statement to the Department of Alcohol and Drug 4. B Programs. Licensee did not ensure Decedent was afforded safe, healthful and comfortable

I 5. accommodations to meet Decedent's needs.

A

6. Licensee staff did not complete the required Resident Health Screening for Decedent B

7. Licensee did not ensure its counseling staff was licensed, certified, or registered six B ; months from date of hire. ! 8. Licensee failed to ensure personnel are tested for Tuberculosis annually. B

INVESTIGATIVE SUMMARY

Investigative Procedure Complaint Analyst (Hereinafter "CA Alatorre") made an unannounced investigative visit to Narconon of Northern California ("Licensee") at the above address to investigate death investigation number 1 0-084D and complaint numbers 10-030, 10-059, 10-152, and 11-030 on November 7, 2011 and November 8, 2011, respectively.

Upon arrival at the Licensee's address, CA Alatorre presented Licensee's Senior Director of Administration, Nathan Tuddenham (Hereinafter "SDA Tuddenham"), with a signed Notice of Inspection of Confidential Records and a signed Notice of Retention of Confidential Records. CA Alatorre requested that the documents be dually signed by the Executive Director or designee and requested copies of the two aforesaid documents. SDA Tuddenham returned an executed copy of the Notice of Inspection of Confidential Records and an executed copy of the Notice of Retention of Confidential Records. CA Alatorre subsequently requested a walk-through of the facility. SDA Tuddenham led CA Alatorre on a walkthrough of the facility. CA Alatorre inspected Licensee's resident rooms, medication room, saunas, recreational facilities, and locations wherein group therapy and one and one therapy are held. Licensee's facility was free of debris and clutter, items were stored neatly, and program participant file cabinets were locked.

I HAVE READ AND UNDERSTAND THE ABOVE INFORMATION. PLEASE INITIAL HERE: ___ ;z__--::-7 _____ _ Program/Facility Representative

PAGE:

2 of 18

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I

I

I

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!

I




(916) 322-2911



CA Alatorre spoke with SDA Tuddenham concerning the purpose of the visit. SDA Tuddenham described the operations of the program, staff positions, and the services provided to Licensee's client and residents.

CA Alatorre conducted staff and resident interviews for the purpose of this investigation. CA Alatorre also requested and received medical records and documentation probative to the findings of this investigation. The California Department of Alcohol and Drug Programs maintains a copy of all documents referenced as the basis of a deficiency for the purposes of due process of law and other requirements as provided by statute.

Overview Licensee admitted Resident#1 (Hereinafter "Decedent") to Licensee's residential treatment program on

Decedent's first complaint of occurred on . On ' _ Decedent requested to be transported to the emergency room where J was admitted. On

:Jecedent expired at the .1

a certificate of death was signed by Dr. Steven Smith, M.D. The cause of death was declared by Dr. Steven Smith, M.D. as ; which occurred

prior to Decedent's expiration. Dr. Steven Smith, M.D. further noted that the Decedent suffered :to Decedent's expiration.

Detailed Chronological Manifest of Decedent's Illness _ , a progress note was made my staff member (nursing assistant), Emma Thomas.

Emma Thomas indicated that Decedent had"' J Decedent's temperature was recorded at ·

CA Alatorre did not locate a progress note for Decedent for

On

- . further notation was made "Iff

Emma Thomas documented in Decedent's residential chart, Decedent's temperature was recorded at

.: possible ER" .

On ,I . Emma Thomas documented in Decedent's residential chart, " · · · ··re-check around dinner''.

.A

CA Alatorre did not locate a progress not for Decedent for the recheck that was to occur on the evening of

On. (time not specified), Emma Thomas documented in Decedent's residential chart, "was I, but is starting to ft . "Decedent's temperature was recorded at

Emma Thomas further records, "Will re-check in the PM".

I HAVE READ AND UNDERSTAND THE ABOVE INFORMATION. PLEASE INITIAL HERE: __ .,r;t._-;?_'-.1_,_/ ______ _ Program/Facility Representative

PAGE:

3 of 18



1700 K Street, Sacramento, CA 95811 TOO (916) 445-1942, Fax (916) 322·2658

(916) 322-2911

PROGRAM INVESTIGATIVE REPORT PROGRAM/FACILITY 10 NUMBER: I PROGRAM/FACILITY NAME: l COMPLAINT INVESTIGATION NUMBER: 440009CN Narconon of Northern California 10-0500 REFERENCES: (1) Health and Safety Code Section 11834.01 and California Code of Regulations (CCR), Title 9, Section 10502. Departmental Authority to License.


On~' · ,., Registered Nurse Christina Kuzio, RN/HCO (Registered Nurse/Health Care Officer) documented in r (

CA Alatorre did not locate a of

!"'-

f

I HAVE READ AND UNDERSTAND THE ABOVE INFORMATION. PLEASE INITIAL HERE:------------


PAGE:

4 of 18


PROGRAM INVESTIGATIVE REPORT PROGRAM/FACILITY ID NUMBER: PROGRAM/FACILITY NAME: 440009CN Narconon of Northern California

Department of Alcohol and Drug Pro( Licensing and Certification Di·

1700 K Street, Sacramento, CA TDD (916) 445-1942, Fax (916) 32:0

(916) 322

COMPLAINT INVESTIGATION NUMBE

10-0500 REFERENCES: (1) Health and Safety Code Section 11834.01 and California Code of Regulations (CCR), Title 9, Section 10502. Departmental Authority to License.


when the students (residents) are integrated into the sauna portion of the program. A student cannot continue to the next book until they have completed book two unless medical conditions dictate they are ineligible to participate in that portion of the program. SDA Tuddenham confirmed Decedent was past book two of the program. Decedent's program and medical records confirmed Decedent was past book two and already successfully completed the sauna portion of the program.. ·

SDA Tuddenham subsequently introduced CA Alatorre to Registered Nurse Christina Kuzio prior to inspecting facility medications to audit compliance with California Code of Regulations (CCR), Title 9, Division 4, Chapter 5, Subchapter 3, Article 2, § 10500 et seq. CA Alatorre inspected the medications located in Licensee's medication storage cabinet. All medications were properly labeled, stored, and corresponded with their respective centrally stored medication logs.

At approximately 11 00 hours, CA Alatorre proceeded to ask Registered Nurse Christina Kuzio her recollection of the condition of the Decedent at Licensee's facility prior to the Decedent being transportee to the local emergency hospital. At which time, Registered Nurse Christina Kuzio stated "I've been arour long enough to know when I need to have representation and what I need to do to protect my license. I will not speak to you without representation present." At which time, CA Alatorre concluded the interview and continued to tour the facility. CA Alatorre advised SDA Tuddenham that CA Alatorre would not objec to allowing Registered Nurse Christina Kuzio's legal representation be present during an interview, but C1 Alatorre did need to ascertain what Registered Nurse Christina Kuzio's observations of the Decedent wer in order to complete CA Alatorre's investigation.

At approximately 1600 hours, SDA Tuddenham informed CA Alatorre that Registered Nurse Christina Kuzio was willing to speak with her without legal counsel present. Registered Nurse Christina Kuzio statec that she did not initially understand the purpose of CA Alatorre's visit and where CA Alatorre was from. CA Alatorre advised Registered Nurse Christina Kuzio that CA Alatorre did not object to her having counsel present and her waiver of such was of Registered Nurse Christina Kuzio's own informed consent. Registered Nurse Christina Kuzio thereafter acknowledged CA Alatorre's statement and cooperated with CA's investigation and interview. CA Alatorre asked Registered Nurse Christina Kuzio what her recollection of Decedent was. Registered Nurse Christina Kuzio confirmed that she did recall Decedent and recalled that multiple advisements were provided to the Decedent that _ should go to a hospital if

did not feel well. Registered Nurse Christina Kuzio relayed Decedent fervently refused as Decedent did not .: which made it • onerous for Decedent to seek treatment. Registered Nurse Christina Kuzio stated that the Decedent was closely monitored and was seen by a nurse practitioner that works with the program. Registered Nurse Christina Kuzio stated that the nurse practitioner had prescribed the Decedent prescription and told the Decedent that if conditior worsened to go the emergency room. Registered Nurse Christina Kuzio further stated the death of the Decedent was "the only time something like this has happened". Registered Nurse Christina Kuzio and SDA Tuddenham both acknowledged there was not a written policy concerning potential imminent illness and injury at the time of Decedent's expiration. CA Alatorre asked Registered Nurse Christina Kuzio if the Decedent was in the Sauna portion of program. Registered Nurse Christina Kuzio confirmed the

I HAVE READ AND UNDERSTAND THE ABOVE INFORMATION. PLEASE INITIAL HERE:--#______,,__ _____ _

ProgramJFacility Representative

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Department of Alcohol and Drug Pn Licensing and Certification [

1700 K Street, Sacramento, Ct TOO (916) 445-1942, Fax (916) 3;

(916) 3.

PROGRAM INVESTIGATIVE REPORT PROGRAM/FACILITY ID NUMBER: PROGRAM/FACILITY NAME: COMPLAINT INVESTIGATION NUMB

10-0500 440009CN Narconon of Northern California REFERENCES: ( 1) Health and Safety Code Section 11834.01 and California Code of Regulations (CCR), Title 9, Section 10502. Departmental Authority to License.

(2) Health and Human Services Agency, Department of Alcohol and Drug Programs, Alcohol and/or Other Drug Program Certification Standards. ·

Decedent was not in the Sauna portion and that the decedent was many books (steps) past that phase the program. Registered Nurse Christina Kuzio confirmed that the nursing assistant, Emma Thomas, is longer employed at Narconon of Northern California.

1.

DESCRIPTION OF THE DEFICIENCY: "CLASS A" Licensee did not notify the Department of Alcohol and Drug Programs of Decedent's death until one year after the death of Decedent.

REGULATORY AND/OR CERTIFICATION STANDARD REOUIREMENT(S): California Code of Regulations (CCR), Title 9, Division 4, Chapter 5, Subchapter 3, Artie! 2, §1 0561, Reporting Requirements provides, in part:

" ... (b) Upon the occurrence of any of the events identified in Section 10561 (b) (1) of this subchapter the licensee shall make a telephonic report to department licensing staff within one (1) working day. The telephonic report is to be followed by a written report in accordance with Section 10561 (b) (2) of this subchapter to the department within seven (7) days of the event. If a report to local authorities exists which meets the requirements cited, a copy of such a report will suffice for the written report required by the department ... "

California Code of Regulations (CCR), Title 9, Division 4, Chapter 5, Subchapter 3, Article 2, §10561 (b)(1)(A), provides such qualifying events include the, "(A) Death of any resident from any cause."

SUMMARY: Licensee admitted Decedent to Licensee's residential treatment program on Decedent's first complaint of occurred on . , Decedent requested and was transported to the emergency room where was admitted. On

Decedent expired at the hospital intensive care unit. On . , a certificate of death was signed by Dr. Steven Smith, M.D. The cause of death was declared as

which occurred' _ r')rior to Decedent's expiration. Dr. Steven Smith, M.D. further noted that the Decedent suffered · , prior to decedent's expiration.

On August 12, 2010, Marie Montiero, Field Operations Branch Analyst with the Department of Alcohol and Drug Programs (ADP), contacted Jeff Panelli, Senior Director of Administration at Narconon of Northern California (Hereinafter "SDA Panelli"), to inquire about Decedent's death.

SDA Panelli told Ms. Montiero that there was a death at the facility; however it was over a year ago. SDA Panelli further stated that because the death did not happen at the facility, it was not reported to ADP.

I HAVE READ AND UNDERSTAND THE ABOVE INFORMATION. PLEASE INITIAL HERE: --~-~_-_v.-,<7 ______ _ Program/Facility Representative

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Department of Alcohol and Drug Prog Licensing and Certification Di~

1700 K Street, Sacramento, CA £ TDD (916) 445-1942, Fax (916) 322

(916) 322·

COMPLAINT INVESTIGATION NUMBE

10-0500 REFERENCES: (1) Health and Safety Code Section 11834.01 and California Code of Regulations (CCR). Title 9, Section 10502. Departmental Authority to License.


SUMMARY: CA Alatorre randomly reviewed Licensee's personnel files to audit compliance with California Code of Regulations, Title 9, Chapter 5, Subsection 2, §1 0500, et seq.

Upon review oft i~"'"""See's files, CA Alatorre observed staff member. personnel file. personnel file reflects that _ 's first

. ___ ... ls next conducted one year and one month later (13 months later) on ~-

Based on review of employee _ -· ____ _ 's personnel file, Licensee is noncompliant with CCR, Title 9, Division 4, Chapter 5, Subchapter 3, Article 2, §1 0564(c) (1 ).

NOTICE OF DEFICIENCY -It is important that the licensee complies with regulations and the instructions of this Notice of Deficiency. Failure of the licensee to comply may result in other_ possible enforcement actions, such as license suspension or revocation. ·

_- - • -- = -· _- • - - -· -· -

NOTICE OF DEFICIENCY (FOR VIOLATION OF. CCR, TITLE 9, CHAPTER 5 SECTION 10500 et seq. -The licensee shall submit written verification of correction for the ClassAdefigiency(ies) identified in this notice of deficiency to ADP within 10 days of receiptof thenotice.ofdeficiency. Thewrltten · . ·. verification shall substantiate that the deficiency(ies) have beencorrected alld specify the datewhen thE deficiency(ies) were corrected. If the licenseE3. cannot correct the deficiency(ies).~ithin 1 Oda"yis of . receipt ofthis notice, the licensee shall submita written Corrective Action Plan (CAP} to: Manager, - . Program Compliance Branch, Departmentof Alcohol and DrugPrograrns, Licensing and Gertification · · Division, 1700 KStreet,> Sacramento, CA 95811-4037; "The CAP shall includE? what steps thelicensee has taken to correct the deficiency(ies);substantiate why the defiCien~y(ies) cannot be corrected as·· specified in this notice; and specify whenthedefiCiency will be.corrected. The_\yritten VE!rification.of correction or 'Nritten CAP shall be postmarked. no later than the date(s) specified in thisnotice. The licensee shaHsubmit written verificatiOn of correction for-the Class Band Cdeficiency(ies) identified in this notice of deficiency to ADPwithin 30 days of receiptof the notice of defid~ncy.:lf the licensee cannot correctthe deficiency(ies) within 30 daysof receiptof thisnotice; th(31icenseeshall submit a written Corrective Action Plan (CAP) to:. Manager, Program ComplianceBrallch)Q~partment ofAicohol and Drug Programs, Licensing and Certification Division; -1700. K Street, Sacrcl!Jleilto;'CA95811-4037: The CAP shall includewhat steps the licensee has taken to correct the deflciE!hcy(ies ); substantiate why: the deficiency(ies)carinot be correCted as specifiedin this notice; ahd specify when the deficiencywill' · be corrected. The written verification of correction or written CAP shall be postmarked no later than the date(s) specified in this notice. · · · - .· · · · ·

Penalt : Failure to correct the above cited deficienc ies shall result in the assessment of a civil ·

I HAVE READ AND UNDERSTAND THE ABOVE INFORMATION. PLEASE INITIAL HERE: k-v 7 Program/FacJI'ity Representative

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Department of Alcohol and Drug Pro£ Licensing and Certification Oil

1700 K Street, Sacramento, CA ! TOO (916) 445-1942, Fax (916) 322

(916) 322


COMPLAINT INVESTIGATION NUMBE 10-0500

REFERENCES: (1) Health and Safety Code Section 11834.01 and California Code of Regulations (CCR), Title 9, Section 10502. Departmental Authority to License. (2) Health and Human Services Agency, Department of Alcohol and Drug Programs, Alcohol and/or Other Drug Program Certification Standards.

penalty of $50 per day for each Class Adeficiency, beginning on the 11 day after receiving this notice and will continue to accrue until the date~ the licensee submits verifi9ation thatthedeficiency(ies) are corrected or until the date awritten CAP is received and approved~· The date of submission by the licensee ofthe written verification ofcorrection, or the written CAP, shall be the date that it is postmarked . . The ma)(imum d~ilycivil penaltyforthe deficiency(ies) shall.not exceed.one hundredanc fifty dollars{$150) pefday. - ·. · .· • . · .· . . . .· .. . . . · . . ·. . · _ Failure tp cqrrect the above cited deficiency(ies) shall result in the assessment of a civil penalty of $50 perday for each Class Bdefidency(ies)al"ld$25 per day for each. Class C deficiency(ies), beginning On the 31st day after receiving this notice and will continue to accrue until thedatethelicenseesubmits verification that the deficiency(ies) are corrected qr until the date a written CAP is received and · -approved.· Thedateofsubniission by the licensee ofthewritten ve-rification of correction; or the written

. CAP, shall he the date that it is postmarked. The maximum daily civil penalty for the deficieocy(ies). shall not exceed one hundred and fift dollars $150 erda . ·

PROGRAM INVESTIGATIVE REPORT SUPPLEMENTARY INFORMATION

IT IS IMPORTANT THAT THE PROGRAM/FACILITY COMPLY WITH THE CALIFORNIA CODE OF REGULATIONS (CCR), TITLE 9.

* * *

NOTICE OF DEFICIENCY- Title 9, Chapter 5, Sections 10543 & 10544, of the California Code of Regulations (CCR), requires the Department complaint investigator/reviewer to prepare a written NOD at the completion of each complaint investigation/licensing compliance review listing all deficiencies noted. The NOD is made a part of the licensing records for the facility and the licensing agency, and is available for public review. Care is taken not to disclose any confidential information in the report. Inquiries concerning the location, maintenance, and content of these reports may be directed to the Department of Alcohol and Drug Programs, Licensing and Certification Division, 1700 K Street, Sacramento, CA 95814-4037.

DEFICIENCIES- A deficiency is a failure to comply with any provision of the regulations pursuant to Chapter 7.5 of Part 2 of Division 10.5 of the Health and Safety Code. The NOD shall specify: the section number, title, and code of each statute or regulation which has been violated; the manner in which the licensee has failed to comply with a specified statute or regulation, and the particular place or area of the facility in which it occurred; the date by which each deficiency shall be corrected; amount of the civil penalty to be assessed in accordance with Title 9, Chapter 5, Sections 10547, CCR, and the date the Department shall begin to assess the penalty, if the licensee fails to correct the noticed deficiencies or submit a CAP.

WRITTEN NOTIFICATION TO DEPARTMENT- The licensee shall submit to the Department written verification of correction for each deficiency identified in this notice of deficiency (NOD). The written verification shall substantiate that the deficiency has been corrected and specify the date when the

I HAVE READ AND UNDERSTAND THE ABOVE INFORMATION. PLEASE INITIAL HERE: __ ....4_~____,-?'---, ------7 17of18


PAGE:


PROGRAM INVESTIGATIVE REPORT PROGRAM/FACILITY 10 NUMBER: PROGRAM/FACILITY NAME: 440009CN Narconon of Northern California

Department of Alcohol and Drug Pre Licensing and Certification D

1700 K Street, Sacramento, CA TDD (916) 445-1942, Fax (916) 32

(916)32

COMPLAINT INVESTIGATION NUMB 10-0500

REFERENCES: (1) Health and Safety Code Section 11834.01 and California Code of Regulations (CCR), Title 9, Section 10502. Departmental Authority to License. (2) Health and Human Services Agency, Department of Alcohol and Drug Programs, Alcohol and/or Other Drug Program Certification Standards.

deficiency was corrected. If the licensee cannot correct a deficiency within the days specified in this NOD, the licensee shall submit a written CAP to: Manager, Programs Compliance Branch, Department Alcohol and Drug Programs, Licensing and Certification Division, 1700 K Street, Sacramento, CA 9581' The CAP shall include what steps the licensee has taken to correct the deficiency (ies); substantiate wr

the deficiency cannot be corrected as specified in this NOD; and indicate the specific date when the deficiency (ies) will be corrected. The written verification of correction or written CAP shall be postmarkE no later than the date specified in this NOD.

CLASS A DEFICIENCIES- Due to the imminent danger to residents, Class A deficiencies must be abated or eliminated immediately. An immediate civil penalty of fifty dollars ($50) is assessed against the licensee upon the discovery of each Class A deficiency described in this NOD. The civil penalty will continue to accrue until the licensee submits verification that each deficiency is corrected. Failure of the licensee to comply may result in other possible enforcement actions, such as license suspension or revocation.

CLASS B DEFICIENCIES- Due to the potential danger of the health and safety of residents, the time period to correct the Class B deficiencies may be less than thirty (30) days if the reviewer determines the deficiency is sufficiently serious to require correction within a shorter period of time.

ALL OTHER DEFICIENCIES- The licensee shall submit to the Department written verification of correction for each deficiency identified in this NOD within thirty (30) days of receiving this NOD. Failure to correct the deficiencies described in this NOD by the date specified shall result in the assessment of a civil penalty of fifty dollars ($50) per day for each Class B deficiency and twenty-five dollars ($25) per day for each Class C deficiency, beginning on the 31st day after the receipt of this NOD and will continue to accrue until the date the licensee submits verification that all deficiencies are corrected or until the date a written CAP is received and approved by the Department. The date of submission by the licensee of the written verification of correction by the licensee shall be the date it is postmarked. The maximum daily civil penalty for all deficiencies shall not exceed one hundred and fifty dollars ($150) per day.

CORRECTIVE ACTION PLAN {CAP)- Title 9, Chapter 5, Section 10545, CCR, allows the licensee to submit a CAP for those Class B or C deficiencies which cannot be corrected by the date specified in the NOD. The licensee shall send a written CAP addressed to the Manager of the Programs Compliance Branch, Department of Alcohol and Drug Programs, Licensing and Certification Division, 1700 K Street, Sacramento, CA 95814-4037, postmarked no later than the date specified in the NOD. The written CAP shall include: what steps the licensee has taken to correct the deficiency; substantiate why the deficiency cannot be corrected by the date specified in the NOD; and specify when the deficiency will be corrected. Within ten (1 0) days of receipt of the CAP, the Department shall notify the licensee, in writing by first class mail, whether the CAP has been approved.

I HAVE READ AND UNDERSTAND THE ABOVE INFORMATION. PLEASE INITIAL HERE: ---~---I':Z----Program/Facility Representative

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COMPLAINT FORM D PRIORITY 10-0500 · Type of Investigation: DEATH INVESTIGATION Type of Program:...

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