narconon watsonville 2010 death investigation

8/11/2019 Narconon Watsonville 2010 Death Investigation

1/20

State of California-Health and Human Services Agency

ADP 7350, Revised 4/09

COMPLAINT FORM

This form

is intended to document complaints received

Reported

I n 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

Licensing and Certification

1700 K Street, Sacramento,

TDD

916) 445-1942, Fax 916

916

D

PR OR TY

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.

YES

COMPLAINT

RECORDED

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

COMPLETE

FOR

COUNSELOR

MISCONDUCT

COMPLAINTS

COUNSELOR

NAME CERTIFYING

ORGANIZATION

CERTIFICATION OR

EXPIRATION

REGISTRATION NO. RENEWAL

D

COUNSELOR COMPLAINT

(90-DAY)

DUE

DATE:

ALLEGATION

NATURE

OF

COMPLAINT

REGULATION STANDARD)

10561(b)(1)(A)

A

.::lient

was

enrolled in the

program on

J

Client died on o

I

t the hospital

due

to


2/20

ASSIGNMENT INFORMATION

4

ASSIGNED FIELD OPERATIONS ANALYST:

Marie Montiero-Gomez

DATE COMPLAINT ASSIGNED:

11/6/2011 (to Al

ASSIGNED COMPLAINT INVESTIGATOR: - J - : - B ~ p a r k s - \ ( \ j ~ f . : : + Q n f ~

b

DATE INVESTIGATION WAS INITIATED:

11/6/201

1\ 1-\ \_C\

C y 0

INVESTIGATION FINDINGS

ALLEGATION

(REGULATION

I

STANDARD)

RESULT CLASS

ALLEGATION

(REGULATION

I

STANDARD)

RESULT

1.10561 (b)(1)(A) SUBSTANTIATED A

6.

10567(a} SUBSTANTIATED

2. 10561 (b)(1)(A} SUBSTANTIATED

A

7.13010(a}/10563

SUBSTANTIATED

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

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

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 \


3/20

State of California-Health and Human Services

Agency

ADP 7350, Revised 4/09

COMPLAINT FORM

This form s intended to document complaints received

Reported 0 In Person

0 By Letter or E-mail

D By

FAX

~ y

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

Department

of

Alcohol and Drug

Licensing and Certificatio


TDD (916) 445-1942, Fax (916

(916

~ P R I O R I T Y

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.

YES

~

COMPLAINT

RECORDED

BY: J. lto-Orille

DATE RECEIVED: February 25, 2011

COMPLETE FOR COUNSELOR M ISCONDUCT COMPLAINTS

COUNSELOR

NAME

CERTIFYING ORGANIZATION

CERTIFICATION OR EXPIRATION

REGISTRATION

NO.

RENEWAL

D

COUNSELOR COMPLAINT (90-DAY) DUE

DATE:

ALLEGATION

NATURE

OF

COMPLAINT

(REGULATION STANDARD

Complainant's

was a

client at

the facility in

r

Clie

10561(b)(1)(A)

went into the

hospital

in

after being

hospital for about Complainant feels that death

occurrecfoe Ciwse

of the

treatment

the facility. Complainant stated that is

concerned

that the practices of the sauna treatment

/


4/20

\

-

ASSIGNMENT INFORMATION

/

.

;

SSIGNED FIELD OPERATIONS ANALYST:

Michael Allen DATE COMPLAINT ASSIGNED:

J

l

;_ L } f t V ~

\

ASSIGNED COMPLAINT INVESTIGATOR: DATE INVESTIGATION WAS INITIATED:

INVESTIGATION FINDINGS

I

I

ALLEGATION

(REGULATION I STANDARD)

RESULT CLASS

ALLEGATION

(REGULATION I STANDARD)

RESULT

COUNSELOR MISCONDUCT COMPLAINT FINDINGS

ALLEGATION

RESULT ORDER

FOLLOW UP INVESTIGATION

RECOMMENDED CATEGORY

O

FOLLOW-UP:

FOLLOW-UP VIOLATION (S) RESULTS

CLASS FOLLOW-UP VIOLATION (S) RESULTS

CLOSURE INFORMATION

INVESTIGATION COMPLETED BY:

DATE O 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:

Pa


5/20

STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY

DEP RTMENT OF LCOHOL ND DRUG PROGR MS

1700 K STREET

SACRAMENTO, CA 95811-4037

TTY/TDD

(800)

735-2929

(916)

322-2911

Dear

RE: Complaint Number 10-050D/1 0-257D

EDMUND

G

BROWN JR

ove

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

f l x ~

0llT .,

l om

DO YOUR PART TO HELP CALIFORNIA SAVE

ENERGY

For energy saving tips, visit the Flex Your Power website

at

http://www. vpower.org


6/20

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].

~ i n c e r e l y

[

~ . . f 01 < ~ ~ ~ ) . ./

: ~ i ~ / \ i

\ ~ : z ( ~ A L

.

~ ~

Complaint Analyst

0

Program Compliance Branch

Licensing and Certification Division


7/20


DEP RTMENT OF LCOHOL ND DRUG PROGR MS

1700 K STREET

SACRAMENTO, CA 95811

T (916) 445-1942

(916) 322-2911

March 30, 2012

Daniel Mason, Director

Nathan Tuddenham, Director of Administration

Narconon

of

Northern California

262 Gaf fey Road

Watsonville, CA 95076

Dear Mr. Manson and Mr. Tuddenham:

NOTICE

OF CLEARED

DEFICIENCY

-INVESTIGATION

10-050D

EDMUND G. BROWN.

JR.

ove

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 \ ~

\

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


8/20

STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY

ADP

6015l

Revised 01/08

Department of Alcohol and Drug Pro

Licensing and Certification D


CA

TDD (916) 445-1942, Fax (916) 3

(916) 32

PROGRAM INVESTIGATIVE REPORT

PROGRAM/FACILITY ID NUMBER:

I

PROGRAM/FACILITY NAME:

I

COMPLAINT INVESTIGATION NUMB

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 descri

the operations of the program, staff positions, and the services provided to Licensee's client and reside

CA Alatorre conducted staff and resident interviews for the purpose of this investigation. CA Alatorre a

requested and received medical records and documentation probative to the findings of this investigati

The

California Department

of

Alcohol and Drug Programs maintains a copy

of

all documents reference

as the basis of a deficiency for the purposes of due process of law and other requirements as provided

statute.

verview

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 Sm

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 suffer

Decedent's expiration.

Detailed Chronological Manifest

o

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 10:30AM, 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

On J Jime not specified), Emma Thomas documented

in

Decedent's residential chart, llwa

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 INITIALHERE

Program/Facility Representative

PAGE:

3

of

8


9/20


10/20

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 ofAlcohol 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

o

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


11/20


ADP 6015L, Revised 01/08

Department of

Alcohol and

Drug P


1700 K Street, Sacramento, C

TDD (916)

445-1942, Fax (916) 3

(916) 3


PROGRAM/FACILITY ID NUMBER: 1PROGRAM/FACILITY NAME: I COMPLAINT INVESTIGATION NUM


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 ~ L S

1

THE INVESTIGATION:

1.

Licensee did not notify the Department of Alcohol and Drug Programs of Decedent's

A

eath 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.

3.

Licensee did not possess policies and procedures ensuring Decedent sought timely

A

medical treatment.

4.

Licensee provided an inaccurate statement to the Department of Alcohol and Drug

B

rograms.

:


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

onths from date of hire.

I

8.

Licensee failed to ensure personnel are tested for Tuberculosis annually.

INVESTIGATIVE SUMMARY

8

/

{ l Q A J

nvestigative Procedure

Complaint Analyst (Hereinafter CA Alatorre ) made an unannounced investigative visit

to

Narconon o

Northern California ( Licensee ) at the above address to investigate death investigation number 10-084

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 Inspectio

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. License

facility was free

of

debris and clutter, items were stored neatly, and program participant file cabinets we

locked.

I HAVE READ AND UNDERSTAND THE ABOVE INFORMATION. PLEASE INITIAL

HERE


PAGE:

2 of

18


12/20


ADP 6015L. Revised

02108


Department of Alcohol

and Drug

P

Licensing

and

Certificatio

1700

K Street. Sacramento.

TDD 916) 445-1942, Fax 916)

916)

PROGRAM/FACILITY ID NUMBER:

I

PROGRAM/FACILITY NAME:

I

COMPLAINT INVESTIGATION NUM


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

ADDRES S Street, City and Zip):

262 Gaffey Road, Watsonville, CA 95076

TYPE OF INVESTIGATION:

D COMPLAINT D

FOLLOW-UP

UNLICENSED ~ D E T H

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

RESIDENTIAL NONRESIDENTIAL

AOD LICENSED

D

DMC CERTIFIED

D

DETOXIFICATION

D ADOLESCENT

D NTP D

D PERINA

COUNSELOR MISCONDUCT- The Counselor

Investigative Report may be referred upon.

AOD CERTIFIED

COUNTY

OPERATED CDCR AFTER CARE PROGRAM

THE FOLLOWING INVESTIGATIVE REPORT IS BEING ISSUED

S

A RESULT OF THE INVESTIGATIO

D NO DEFICIENCY Licensed and/or Certified Programs)

~ D E T H INVESTIGATION Licensed and/or Certified Programs)

~ C E R T I F I C T I O N AOD Certified Programs)

~ N O T I C E

OF DEFICIENCY Licensed Programs)

NOTICE OF OPERATION IN VIOLATION OF LAW Unlicensed Programs)

D ~ T E R D E P R T M E N T L R E F E R R L

The investigation was conducted

in

accordance with

California Code

of

Regulations CCR), Title

9,

Chapter

5 and/or the lcohol

and/or Other

Program Certification Standards

which

may include the following: inspeCtion

of

the program premises, review of program

policies,

procedure

staff

and

resident file{s),

and

the interview of residents

and staff.

In addition,

the

complaint investigator shall notify the

licensed and/or certifi

program/facility director or

his/her designee of the allegation s) during the exit conference.

The ADP 9080, Detail

Supportive Information form

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:


13/20


ADP 6015L, Revised 01108

Department of Alcoho l and Drug P



TDD (916) 445-1942, Fax (916)

(916)


PROGRAM/FACILITY

ID

NUMBER: I PROGRAM/FACILITY NAME: I COMPLAINT INVESTIGATION NUM

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

r

TH FOLLOWING DEFICIENCY IES) WERE IDENTIFIED AND SUBSTANTIATED DURING THE COURSE

O

CLA

TH 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.


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

nvestigative Procedure

Complaint Analyst (Hereinafter "CA Alatorre") made an unannounced investigative visit to Narconon o

Northern California ("Licensee") at the above address to investigate death investigation number 10-08

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 Inspecti

Confidential Records and a signed Notice

of

Retention

of

Confidential Records. CA Alatorre requeste

that the documents

be

dually signed by the Executive Director or designee and requested copies of th

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. Licens

facility was free of debris and clutter, items were stored neatly, and program participant file cabinets w

locked.

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

z__ :: 7

______


PAGE:

2 of 18


14/20

STATE

OF

CALIFORNIA-

HEALTH

AND HUMAN

SERVICES

AGENCY


Department of Alcohol and Drug P



TDD (916) 445-1942, Fax (916)

(916)


PROGRAM/FACILITY ID

NUMBER:

I PROGRAM/FACILITY

NAME:

I

COMPLAIN T INVESTIGATION NUM


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 desc

the operations of the program, staff positions, and the services provided to Licensee's client and resid

CA Alatorre conducted staff and resident interviews for the purpose of this investigation. CA Alatorre

requested and received medical records and documentation probative to the findings

of

this investiga

The California Department

of

Alcohol and Drug Programs maintains a copy

of all

documents referenc

as the basis

of

a deficiency for the purposes of due process of law and other requirements as provide

statute.

verview

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

o

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

a certificate

of

death was signed

by Dr.

Steven S

M.D. The cause

of

death was declared by Dr. Steven Smith, M.D. as ; which occurre

prior to Decedent's expiration.

Dr.

Steven Smith, M.D. further noted that the Decedent suffe

: 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 '


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,


:

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 eveni

On. (time not specified), Emma Thomas documented

in

Decedent's residential chart, w

I,

ut

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

INFORMATIO N. PLEASE INITIAL HERE: ,r;t._-;?_ -.1_,_/


PAGE:

3

of

18


15/20

STATE

OF

CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY


Department of Alcohol and Drug P



TOO 916) 445-1942, Fax 916)

916)

PROGR M INVESTIG TIVE REPORT

PROGRAM/FACILITY 10 NUMBER: I ROGRAM/FACILITY NAME: l COMPLAINT INVESTIGATION NUM


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.

O n ~

.

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

HER E:- - - - - -- - - -- -


PAGE:

4

of

8


16/20



PROGR M INVESTIG TIVE REPORT

PROGRAM/FACILITY ID NUMBER: PROGRAM/FACILITY NAME:

440009CN Narconon of Northern California

Department of Alcohol and D

Licensing and Certific

1700 K Street, Sacrame

TDD (916) 445-1942, Fax

COMPLAINT INVESTIGATION

10-0500

REFERENCES: 1) Health and Safety Code Section

11834.01

and California Code of Regulations (CCR), Title 9, Section

10502.

Departmental Authority

to

Li

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

when the students (residents) are integrated into the sauna portion of the program. A student can

continue to the next book until they have completed book two unless medical conditions dictate the

ineligible to participate in that portion of the program. SDA Tuddenham confirmed Decedent was

book two of the program. Decedent s program and medical records confirmed Decedent was past

two and already successfully completed the sauna portion

of

the program..

SDA Tuddenham subsequently introduced CA Alatorre to Registered Nurse Christina Kuzio prior t

inspecting facility medications

to

audit compliance with California Code of Regulations (CCR), Title

Division 4, Chapter 5, Subchapter 3, Article 2,

10500 et seq. CA Alatorre inspected the medicati

located in Licensee s medication storage cabinet. All medications were properly labeled, stored,

a

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 trans

to

the local emergency hospital. At which time, Registered Nurse Christina Kuzio stated

I've been

long enough

to

know when I

need to

have representation

nd

what I need

to o

to

protect my licen

will

not

speak

to

you without representation present.

At which time, CA Alatorre concluded

the

in

and continued

to

tour the facility. CA Alatorre advised SDA Tuddenham that

CA

Alatorre would no

to allowing Registered Nurse Christina Kuzio s legal representation be present during

an interview

Alatorre did need to ascertain what Registered Nurse Christina Kuzio s observations of the Decede

in order

to

complete CA Alatorre s investigation.

At approximately 1600 hours, SDA Tuddenham informed CA Alatorre that Registered Nurse Christ

Kuzio was willing

to

speak with her without legal counsel present. Registered Nurse Christina Kuzi

that she did not initially understand the purpose of CA Alatorre s visit and where CA Alatorre was f

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 c

Registered Nurse Christina Kuzio thereafter acknowledged CA Alatorre s statement and cooperate

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 Dec

and recalled that multiple advisements were provided

to

the Decedent that _ should go to a hos

did not feel well. Registered Nurse Christina Kuzio relayed Decedent fervently refused as De

did not

:

which made it onerous for Decedent

to

seek treatmen

Registered Nurse Christina Kuzio stated that the Decedent was closely monitored and was seen b

nurse practitioner that works with the program. Registered Nurse Christina Kuzio stated that the n

practi tioner had prescribed the Decedent prescription and told the Decedent that if

worsened to go the emergency room. Registered Nurse Christina Kuzio further stated the death of

Decedent was the only time something like this has happened . Registered Nurse Christina Kuzio

SDA Tuddenham both acknowledged there was not a written policy concerning potential imminent

and injury at the time of Decedent s expiration. CA Alatorre asked Registered Nurse Christina Ku

Decedent was in the Sauna portion of program. Registered Nurse Christina Kuzio confirmed

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

ProgramJFacility

Representative

PA

6

o


17/20



Department

of Alcohol

and D



TOO (916) 445-1942,

Fax




10 0500


REFERENCES: (

1)

Health and Safety Code Section 11834.01 and California Code of Regulations (CCR), Title 9, Section 10502. Departmental Authority to Li

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

Decedent was not

in

the Sauna portion and that the decedent was many books (steps) past that p

the program. Registered Nurse Christina Kuzio confirmed that the nursing assistant, Emma Thoma

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 dea

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,

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

staf f 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

a

resident from

any

cause.

SUMMARY:

Licensee admitted Decedent to Licensee's residential treatment program on

Decedent's first complaint of occurred

on

. , Dec

requested and was transported to the emergency room where was admitted.

On

Decedent expired at the hospital intensive care unit. On . , a certif

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. f

noted that the Decedent suffered , prior to

decedent's expiration.

On August 12, 2010, Marie Montiero, Field Operations Branch Analyst with the Departm

Alcohol and Drug Programs (ADP), contacted Jeff Panelli, Senior Director

of

Administra

Narconon

of

Northern California (Hereinafter SDA Panelli ), to inquire about Decedent'

death.

SDA

Panelli told Ms. Montiero that there was a death at the facility; however it was over

ago. SDA Panelli further stated that because the death did not happen at the facility, it w

reported

to

ADP.

I

HAVE

READ AND UNDERSTAND THE ABOVE INFORMATION. PLEASE INITIAL HERE: - - ~ - ~ _ - _ v . - < 7

_


PA

7

o


18/20

STATE OF

CALIFORNIA

HEALTH AND HUMAN SERVICES AGENCY








TDD (916) 445-1942, Fax


10-0500

REFERENCES: (1) Health and Safety Code Section

11834.01

and California Code of Regulations (CCR). Title

9,

Section

10502.

Departmental Authority to Li

(2) Health and Human Services Agency, Department

of

Alcohol and Drug Programs, Alcohol and/or Other Drug Program Certification Standa

SUMMARY:

CA Alatorre randomly reviewed Licensee's personnel files to audit compliance with Calif

Code

of

Regulations, Title

9,

Chapter

5,

Subsection

2, 1

0500, et

seq.

Upon review

oft i ~ ' S e e ' 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 noncomplian

CCR, Title

9,

Division

4,

Chapter

5,

Subchapter

3,

Article

2, 1

0564(c) (1 ).

NOTICEOF DEFICIENCY I t is important that the licensee complies with regulations and t

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.

_-

- _- - -

NOTICEOF DEFICIENCY FOR VIOLATION OF. CCR TITLE 9 CHAPTER 5 SECTION 10500

The

licensee shall submit written verification of correction for the ClassAdefigiency(ies) identifi

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 datew

deficiency(ies) were corrected. I f he licenseE3. cannotcorrect the d e f i c i e n c y i e s ) . ~ i t h i n 1Oda yis o

receipt ofthis notice, the licensee shall

submita

written Corrective Action Plan (CAP}

o:

Manage

Program Compliance Branch, Departmentof Alcohol and DrugPrograrns, Licensing and Gertifica

Division, 1700 KStreet,> Sacramento, CA 95811-4037; "The CAP shall includE? what steps thelice

has taken to correct the deficiency(ies);substantiate why the

d e f i C i e n ~ y ( i e s )

cannot

be

corrected

specified

in

this notice; and specify whenthedefiCiency will be.corrected. The_\yritten VE rification

correction or 'Nritten CAP shall be postmarked.no later than the date(s) specified n thisnotice. T

licensee shaHsubmit written verificatiOn

of

correction for-the Class

Band

Cdeficiency(ies) identif

this not ice of deficiency to ADPwithin 30 days of receiptof the notice of

e f i d ~ n c y . : l f

the license

cannot correctthe deficiency(ies) within 30

daysof

receiptof thisnotice; th(31icenseeshall subm

written Corrective

Action

Plan (CAP) to:. Manager, Program

C o m p l i a n c e B r a l l c h ) Q ~ p a r t m e n t

ofA

and

Drug Programs, Licensing and Certification Division;

-1700. K

Street, Sacrcl Jleilto;'CA95811-

The

CAP

shall includewhat steps the licensee has taken to correct the deflciE hcy(ies

);

substantia

the deficiency(ies)carinot

be

correCted as specifiedin this notice; ahd specify when the deficien

be corrected.

The

written verification of correction or written CAP shall be

postmarked no

later t

date(s) specified in this notice. -

Penalt :

Failure to correct the above cited deficienc ies shall result

in

the assessment of a civi

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

7

Program/FacJI'ity Representative

PA

6


19/20





1700

K Street, Sacrame

TOO

(916) 445-1942, Fax





10-0500

REFERENCES: 1)

Health and Safety Code Section

11834.01

and California Code

of

Regulations (CCR), Title

9,

Section

10502.

Departmental Authority

to

Li


penalty of $50 per day for each Class Adeficiency, beginning on the 11 day after receiving this n

and will continue to accrue until the d t e ~ the licensee submits verifi9ation thatthedeficiency(ies)

corrected or until the date awritten CAP is received and p p r o v e d ~ The date of submission by th

licensee ofthe written verification

ofcorrection

or the written

CAP

shall be the date that t is

postmarked . .

The

ma)(imum d ~ i l y c i v i l penaltyforthe deficiency(ies) shall.not exceed.one hundre

fifty dollars{$150) pefday. -

. . . . . . . . .

.

Failure tp cqrrect the above cited deficiency(ies) shall result in the assessment of a civil penaltyo

perday for each Class Bdefidency( ies)al"ld$25per day for each.ClassC deficiency(ies), beginni

the

31st day

after receiving this notice and will continue to accrue until

thedatethelicenseesubm

verification that the deficiency(ies) are corrected qruntil the date a written CAP is received and

approved.

Thedateofsubniission

by the licensee

ofthewritten

ve-rification

of

correction; or

the

w

.CAP, shall he the date that it is postmarked. The maximum daily civil penalty for the deficieocy(

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 O

REGULATIONS CCR), TITLE 9

*

*

*

NOTICE OF

DEFICIENCY

Title 9, Chapter 5, Sections 10543 & 10544, of the California Code o

Regulations (CCR), requires the Department complaint investigator/reviewer to prepare a written

N

the completion of each complaint investigation/licensing compliance review listing

all

deficiencies n

The NOD is made a part

of

the licensing records for the facility and the licensing agency, and is av

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 Departm

Alcohol and Drug Programs, Licensing and Certification Division, 1700 K Street, Sacramento, CA

4037.

DEFICIENCIES A deficiency is a failure to comply with any provision of the regulations pursuant

Chapter 7.5 of Part 2 of Division 10.5 of the Health and Safety Code. The NOD shall specify: the

number, title, and code of each statute or regulation which has been violated; the manner in which

licensee has failed

to

comply with a specified statute or regulation, and the particular place or area

facility

in

which

it

occurred; the date by which each deficiency shall be corrected; amount of the civ

penalty to be assessed in accordance with Title 9, Chapter 5, Sections 10547, CCR, and the date

Department shall begin to assess the penalty, if the licensee fails to correct the noticed deficiencie

submit a CAP.

WRITTEN NOTIFICATION TO

DEP RTMENT

The licensee shall submit to the Department writt

verification of correction for each deficiency identified in this notice of deficiency (NOD). The writte

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 _ ~ _ _ _ _ , - ? - - - ,

17o


PA


20/20

STATE OF

CALIFORNIA-

HEALTH AND HUMAN SERVICES AGENCY



PROGRAM/FACILITY 10 NUMBER: PROGRAM/FACILITY NAME:



Licensing and Certifica

1700 K Street, Sacramen

TDD (916) 445-1942, Fax (


10-0500

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


deficiency was corrected. If the licensee cannot correct a deficiency within the days specified

in

th

NOD, the licensee shall submit a written CAP to: Manager, Programs Compliance Branch, Departm

Alcohol and Drug Programs, Licensing and Certification Division, 1700 K Street, Sacramento, CA 9

The CAP shall include what steps the licensee has taken to correct the deficiency (ies); substantia

the deficiency cannot be corrected as specified in this NOD; and indicate the specific date when th

deficiency (ies) will be corrected. The written verification of correction or written CAP shall be postm

no

later than the date specified in this NOD.

CLASS A DEFICIENCIES Due to the imminent danger to residents Class A deficiencies mu

abated or eliminated immediately.

An immediate civil penalty of fifty dollars ( 50)

is

assessed a

the licensee upon the discovery of each Class A deficiency described in this NOD. The civil penalt

continue to accrue until the licensee submits verification that each deficiency is corrected. Failure

licensee

to

comply may result

in

other possible enforcement actions, such as license suspension o

revocation.

CLASS B DEFICIENCIES Due to the potential danger of the health and safety

of

residents, the t

period to correct the Class B deficiencies may be less than thirty (30) days if the reviewer determin

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.

F

to correct the deficiencies described

in

this NOD by the date specified shall result in the assessme

civil penalty of fifty dollars ( 50) per day for each Class B deficiency and twenty-five dollars ( 25) p

for each Class C deficiency, beginning

on

the 31st day after the receipt

of

this NOD and will continu

accrue until the date the licensee submits verification that all deficiencies are corrected or until the

written CAP is received and approved by the Department. The date of submission by the licensee

written verification of correction by the licensee shall be the date it is postmarked. The maximum d

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 license

submit a CAP for those Class B

or

C deficiencies which cannot

be

corrected by the date specified

NOD. The licensee shall send a written CAP addressed to the Manager of the Programs Complian

Branch, Department

of

Alcohol and Drug Programs, Licensing and Certification Division,

1700

K S

Sacramento, CA 95814-4037 postmarked no later than the date specified in the NOD. The writte

shall include: what steps the licensee has taken to correct the deficiency; substantiate why the defi

cannot be corrected by the date specified

in

the NOD; and specify when the deficiency will be corr

Within ten

1

0) days of receipt

of

the CAP, the Department shall notify the licensee,

in

writing by fir

class mail, whether the CAP has been approved.

narconon watsonville 2010 death investigation

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