Non-compliance follow-up·November 1, 2022

Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced Case Management-Legal Non-Compliance inspection at the facility today. The purpose of today’s visit was to ensure the facility was maintaining substantial compliance as outlined in the Stipulation and Waiver; and Order. The order is effective February 25, 2022 – February 24, 2025. Areas discussed: - Career Smart conducting quarterly audits: The last audit took place in September from 9/6 – 9/8. - On site visits from a member of the governing board: The last visit was August; the next date is 11/18/2022. - Monthly support groups for staff – The last session took place on 10/25/2022. - Additional training hours - The facility requires the staff to complete the hours on a monthly basis. The LPA reviewed training documents to confirm that staff are receiving the required training hours. From 12:35 p.m. – 1:40 p.m., the LPA conducted a medication audit for five (5) residents. - Resident #1 experienced a medication change on 10/15/2022, in which the order was changed from receiving one capsule three times a day to receiving two capsules two times a day. Whereas the staff claim that the original medication was discontinued and was not administered to R1, staff continued to sign off as if R1 received the initial medication and the new medication dosage. - Resident #2 had an as-needed medication (Seroquel) that was administered two (2) times; however, staff only documented that R2 was assisted with the self-administration of this as-needed medication one (1) time. R2 had a PRN for acetaminophen that was administered eight (8) times in two months; however, staff documented that R2 was assisted with the self-administration of this as-needed medication three (3) out of eight (8) times. - Resident #3 had an as-needed medication administered five (5) times in two months; however, staff only documented that R3 was assisted with the self-administration of this as-needed medication three (3) times. 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 reports and appeal rights were reviewed and issued.