Routine inspection (multi-day)·February 9, 2024

At 10:40 am on this day, February 9, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the annual required inspection that was started on January 15, 2024. LPA was granted entry by Ester Ramirez, care staff. LPA met with Elton Brown, administrator, and informed the reason for visit. LPA reviewed 5 resident records and interview 2 residents. LPA inspected the medications. compared with doctor's order on file and LIC622 Centrally Stored Medication and Destruction Records and Medication Administration Record (MAR). LPA observed the following: -at 11:10 a.m. to 11:20 a.m., residents (R1 and R2) LIC602A Physician's Reports were over a year old. -at 11:30 a.m., residents (R1 and R5) half bed rails have no doctor's order on file. -at 11:40 a.m. R1's LIC625 Appraisal/Needs and Service Plan is over a year old. -at 11:55 a.m., resident (R5) LIC9172 Functional Capability Assessment has contradicting information on eating and repositioning. -at 12:10 p.m,, R1 has 15 medications listed on the doctor's order on file; however, R1 has only 7 medications on facility's hand, one of which not on the order. -at 12:30 p.m., most current order of medications for R2 does not have dosage; Baclofen dosage from April 11, 2023 order is not consistent with what the facility has on hand. One medication on the current list but facility does not have the medication -at 1:15 p.m., R3's medications o rder on file for 17 meds but facility only has 11 on hand. Order for Vit D3 is 50 mcg 1 tablet per day, and on facility's hand is 25 mcg and facility administers only 1 tablet per day. ....continued on 809C Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. Failure to submit proof of corrections by plan of correction due dates, and any repeat violation within 12 month period may result in civil penalties. Deficiencies and plan and proof of corrections were discussed with the administrator. Administrator has to leave the facility, and authorized Ester Ramirez to sign and receive this report. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.