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Inspection visit

Follow-up on corrections

STRAWBERRY COTTAGELicense 1976090112 citations on this visit
2 citations recorded

Inspector’s narrative

What the inspector wrote

On 05/03/2023 in conjunction with a subsequent complaint visit control number 31-AS-20230427111039, Licensing Program Analyst (LPA) Rios did an unannounced CASE MANAGEMENT - Deficiencies visit. LPA met with Administrator Designee Ricky Desahagun, LPA spoke with Administrator David Taylor over the phone informed them of the purpose of the visit. On 05/02/2023 during interviews with staff and residents it was revealed resident #3 (R3) had a fall some time in the week of 04/09/2023. Interview with Ricky on 05/03/2023 revealed a nurse from Home Heath had seen R3 who took her vitals and reported no issues. A physical therapist had also visited the resident but informed facility R3 could not continue because resident was complaining of pain when moved. According to Ricky, physical therapy was placed on hold until R3 is examined to determine they are fine to continue with physical therapy. LPA advised Ricky resident needs to receive medical attention to rule out serious injury from fall. Ricky called the Administrator David who informed Ricky, R3 is in hospice. Ricky could not provide to LPA name of hospice or date of admission to hospice for R3. On 05/03/2023 LPA made a follow-up visit to confirm if resident had received medical attention. Administrator David informed LPA R3 was seen by Home Health and is being placed on hospice. Administrator David could not provide name of Hospice or date of admission to hospice. LPA again advised Ricky and David to call 911. Ricky called 911 at 10:55 a.m. and ambulance arrived at 11:38 a.m. to transport R3 to the hospital. On 05/02/2023 LPA observed Ricky count medication and LPA compared the count with Centrality Stored Medication Logs and Medication Administration Records (MAR). LPA observed pill counts were over the total quantity number of pills listed on the prescribed medication bottles for resident #2(R2) and resident #6(R6). LPA spoke with the Administrator David over the phone and Administrator explained, “They shouldn’t do that, I’ve trained them.” In reference to staff pouring pills from one bottle to another. (LIC809-C Continued) (Continued Lic809-C) Per the California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, the following deficiency was observed and cited (Refer to LIC 809-D). Copy of this report provided, appeal form given. Exit interview conducted.

Citations

5 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 87468.1(a)(15)Type B

    (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights:(15)To send and receive unopened correspondence in a prompt manner. This requirement is not met as evidenced by: Based on interviews and observation the Licensee did not ensure R1 received their correspondence in a prompt manner. This posed a potential health and safety or personal rights risk to residents in care.

  • 87645(a)(4)Type A

    (a) A plan for incidental medical and dental care shall be developed by each facility... by compliance with the following:(4)The licensee shall assist residents with self administered medications as needed.This requirement is not met as evidenced by: Based on document review and interviews the Licensee did not ensure R1 was administered medication as prescribed. This poses an immediate health and safety or personal rights risk to residents in care.

  • 87307(a)(3)(A)Type B

    Bed provision and bedding standards for residents

    (a) Living accommodations and grounds shall be related to the facility's function... The following provisions shall apply:(3) ...the licensee shall assure provision of:(A)A bed for each resident...appropriate sized bed. Each bed shall be equipped with good springs, a clean and comfortable mattress...This requirement is not met as evidenced by: Based on interviews and observation the Licensee did not ensure 4 out 6 residents had good spring, clean and comfortable mattresses. This poses a potential health and safety or personal rights risk to residents in care.

  • 87465(g)Type B

    Call 9-1-1 for imminent health threats

    (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis...This requirement is not met as evidenced by: Based on document review and interviews the Licensee did not call 911 for R3 when they were notified R3 had a fall in the facility and R3's health condition changed. This poses a potential health and safety or personal rights risk to residents in care.

  • 87465(h)(5)Type B

    Keep prescriptions in original containers

    (h)The following requirements shall apply to medications which are centrally stored:(5)Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by: Based on observation and interviews the Licensee did not ensure prescribed medication was kept in their original containers for two out of six residents. This poses a potential health and safety or personal rights risk to residents in care.

FAQ · About this visit

Common questions about this visit

What happened during the May 3, 2023 inspection of STRAWBERRY COTTAGE?

This was an other inspection of STRAWBERRY COTTAGE on May 3, 2023. 2 citations were issued: 2 Type B.

Were any citations issued to STRAWBERRY COTTAGE on May 3, 2023?

Yes, 2 citations were issued (0 Type A, 2 Type B). The first citation was for: "(a)Residents in all residential care facilities for the elderly shall have all of the following personal rights:(15)To s..."

What type of inspection was this?

This was an other inspection. other inspections are conducted by CCLD as part of their licensing oversight.

SourceView on CCLDView original report

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Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.