Follow-up on corrections·April 21, 2021

Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced Case Management-Deficiencies inspection visit at the facility today due to deficiencies observed during the investigation of complaint control #31-AS-20200522093556 During today’s investigation, the LPA audited medications. During the medication audit, the LPA was unable to complete an accurate count of medications administered to Resident #1 (R1), as the LPA nor the staff were able to communicate the start date as to when medications were administered. The LPA spoke to Administrator Ella Mastov via phone, whom communicated that they understood the medication count, but the LPA explained that staff needed to be familiar with the system to ensure accuracy. The LPA explained that the staff were unable to communicate the start dates or system for assisting residents with the self-administration of medication. The LPA also shared that there was no documentation to confirm the medication administration system. In addition, the LPA audited training files for Staff #2 and Staff #3 (S2, S3). The LPA observed that the staff only received six hours of initial medication training; yet, S2 and S3 required ten hours of initial medication training per regulation. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted, today's report and appeal rights were reviewed and issued via email. Signatures were obtained.