Alondra Home

Ensure hazardous items are locked and not unattended

Based on observation, the licensee did not comply with the section cited above when LPA observed a knife inside the kitchen sink unlock and laundry detergent on the floor in the laundry room unlock accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.

Maintain physician order documentation in resident record

Based on interview conducted, observation, and records reviewed, R5 uses half bed rail on hospital bed with no doctor’s order, which poses/posed a potential health and safety and personal rights risk to the resident in care.

Conformance with applicable laws and regulations

Based on observation, Fire Extinguisher has a service date of 01/06/25, which poses an immediate health and safety risk to the residents.

Record findings for communicable tuberculosis conditions

Based on records reviewed, R4 do not have TB result on file which poses/posed a potential health, safety or personal rights risk to persons in care.

Give PRN medication by physician order

Based on observation and records reviewed, 5 out of 15 of R5’s medications were checked by LPA and Administrator and observed not administered as directed by physician. Staff did not record medications administered for all 6 residents on 01/14/26 at 08:00AM, which poses/posed an immediate health and safety risk for the person in care.

Document each PRN medication dose taken

Based on interviews and records reviewed, 8 out of 15 medications for R5 were not recorded in the resident’s MAR. Staff did not record medications administered for all 6 residents on 01/14/26 at 08:00AM, which poses a potential health and safety risk for the person in care.

Store centrally held medications in locked secure place

Based on observation, the licensee did not comply with the section cited above when LPA observed staff taking medication cup filled with medication tablets out of an unlock kitchen drawer, which poses an immediate health, safety or personal rights risk to person in care.

Record centrally stored prescriptions and refill data

Based on interview conducted, observation, and records reviewed, all of current R3,R4, R5 and R6’s medications were not recorded in Centrally Stored Medication (Lic 622) record, poses/posed a potential health and safety and personal rights risk to the resident in care.

Facility must keep complete hospice care plan on file

Based on record review, the licensee did not comply with the section cited above when LPA reviewed R1, R2, and R3 whose currently receiving hospice care with no current hospice care plan on file, which poses a potential health or personal rights risk to persons in care.

Maintain physician order documentation in resident record

87608 (a)(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.This requirement is not met as evidenced by: Based on observation and records reviewed, R1 and R2 uses half bed rail on hospital bed with no doctor’s order, which poses/posed a potential health and safety and personal rights risk to the resident in care.

Document each PRN medication dose taken

Based on interview conducted and records reviewed, all residents’ medications were administered on 02/11/25, 02/12/25 and on 02/13/25 at 08:00am. Staff did not recorded into the residents’ Medication Administration Record (MAR) which poses/posed a potential health and safety risk to the resident in care.

Based on interview conducted and records reviewed, last emergency drill conducted was on 07/03/24, which poses/posed a potential health and safety risk to the resident in care.

Ensure hazardous items are locked and not unattended

Based on observation, the licensee did not comply with the section cited above when LPA observed knives stored in kitchen drawer unlock. Cleaning chemicals stored under kitchen sink unlock. LPA observed multiple chemicals in the garage unlock. Garage chemical cabinet in the garage was observed unlock and the outside shed was observed unlock accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.

Store centrally held medications in locked secure place

Based on observation, the licensee did not comply with the section cited above when LPA observed at 10:44AM, the residents’ medications in pharmacy bag on the table in the activity room and the medical closet unlock which poses an immediate health, safety or personal rights risk to person in care.

Record centrally stored prescriptions and refill data

Based on observation and record review, licensee did not comply with the section cited above when R1’s medication Valacyclovir Hcl 1 gram, Pepcid Famotidine 20 mg, and Chewable Ginger 50 mg was not logged in centrally stored list which poses a potential health, safety or personal rights risk to persons in care.

Food quality controls and rejected damaged goods

Based on observation, multiple perishable foods were observed with expired date which poses/posed an immediate health, safety or personal rights risk to persons in care.

Based on records reviewed and interviews, S3 training material do not include dates, trainer’s name and number of hours completed which poses/posed a potential health and safety risk for the person in care.

Obtain required California clearance or exemption

LPA observed S1 at the facility not fingerprinted cleared and not associated the facility which poses/posed an immediate risk to the health and safety of the residents.