Lily of the Valley

Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 out of 1 S4 is not cleared or associated with the facility to be working; which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in 1 out of 1 R1 medication in the refrigerator was kept unlock and accessible, which poses an immediate health, safety or personal rights risk to persons in care.

Requirement for building permit before construction

87305 - Alterations to Existing Buildings or New Facilities (a)Prior to construction or alterations, all facilities shall obtain a building permit. Based on LPA's observation on 09/14/2023 and information obtained the Licensee had converted the garage to a room with a private bathroom without obtaining permits. This poses potential risk to the personal rights of the residents in care

...Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following:(7) Sketches, showing dimensions, of the following: Building(s) to be occupied, including a floor plan that describes the capacities of the buildings...

Keep prescriptions in original containers

87465(h)(5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. LPA observed a bottle of Tramadol over the number of bills. Administrator has transfer old bills to new container of Tramadol which poses an immediate risk to residents in care.

Based on observations the licensee/staff did not comply with the cited section by not screening LPA’s for symptoms of COVID 19 upon entry, which poses and immediate Health and Safety and personal rights risk to persons in care.

Require physician order and label for PRN medication

Incidental Medical and Dental (e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. This requirement has not been met as evidence by The administrator could not locate the PRN for resident #1 antibiotics. Medication was no longer available.

Register of Residents(a) The licensee shall ensure that a current register of all residents in the facility is maintained and contains the following updated information: (b) Registers of residents shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. This requirement has not been met as evidence by a review of facility documents. The administrator did not know what the register was and did not have any updated documents.

Administrator Qualifications:(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (3) Ability to maintain or supervise the maintenance of financial and other records. This requirement is not met as evidence by records review and administrator admission to not follow requirements of maintaining records. Such as reporting requirements. each time a resident was hospitalized.

Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement is not met as evidenced by record review and administrator admission that he never completes incident reports.