Follow-up on corrections·March 7, 2025

Licensing Program Analyst (LPA) Trevor Byrne arrived to the facility to conduct an unannounced Case Management- Deficiencies inspection at 09:59 AM. During today’s visit LPA conducted a physical plant tour, conducted a file review for five (5) residents, conducted a medication review for one (1) resident, interviewed the facility Administrator, one (1) staff member, and four (4) of five (5) residents. Two (2) residents interviewed stated that they believe they are not getting the care they need at the facility. One (1) resident interviewed, Resident #1 (R1) stated that Staff #1 (S1) is unable to communicate in English and this causes discrepancies in the food they are served due to their dietary restrictions and in the administration of their medications. R1 stated that they had previously requested a copy of their Medication Administration Record (MAR) from the facility to verify the accuracy of the medications they are given and facility staff failed to provide the document. R1 stated that they have requested the facility to move them from their current room due to disagreements with their roommate and the facility has refused to move them. R1 stated that there are no activities offered at the facility and their health has declined as a result of the lack of physical activities. The facility Administrator and staff #2 (S2) stated that S1 utilizes Google translate to communicate with residents and understands English well. S2 and the Administrator stated that facility staff observe dietary restrictions of residents and administer medications as prescribed. The Administrator and S2 were unsure if staff failed to provide R1 with a copy of their MAR. The Administrator stated that at the moment the facility has no open beds to move R1 to but stated that they would move R1 from their room when a bed becomes available. The Administrator agreed to interview residents and incorporate activities that interest the facility’s residents. Continued on LIC 809C. During the file review LPA observed R1’s resident #3's (R3) file to be missing from the facility. During medication review LPA observed R1’s MAR to not be filled out and no record of medication’s administrations were logged. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.