Routine inspection (multi-day)·July 28, 2023

At 9:35 a.m., Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced Case Management - Annual Continuation at the facility today continuing the inspection that began on 06/27/2023. At 10:00 a.m., the Administrator arrived at the facility. RECORD REVIEW: Between 10:10 a.m. and 11:20 a.m., the LPA conducted a file review for all residents and staff regularly scheduled and observed the following: Staff have current first aid and training documentation showing required training completed. All personnel/ staff files were in order. Resident records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. The following was noted: one (1) out of four (4) resident files reviewed did not contain a current reappraisal. The Administrator did not reassess and update the reappraisal for Resident #1’s (R1) in the past 12 months (last reappraisal dated 06/26/22). Discussion held with Administrator and the Administrator stated that R1’s reappraisal will be updated. Remaining files reviewed were observed to be in compliance. MEDICATIONS: Between 11:35 a.m. and 12:08 p.m., the LPA conducted a review of medication and medication documentation with the Administrator for four (4) out of four (4) residents and observed the following: R1’s Carvedilol 6.25 mg (take 1 tablet twice a day) had 12 tablets remaining, however the medication was started on 06/28/2023 and the quantity was 60. Resident #2’s (R2’s) Levothyroxine 125 MCG Tablet (take 1 tablet once a day) had 3 tablets remaining, the medication was started on 06/27/2023 and the quantity was 30. Resident #3’s (R3’s) SM Melatonin 5MG (take 1 tablet once a day) had 2 tablets remaining, the medication was started on 06/27/2023 and the quantity was 30. The LPA had a discussion with the Administrator regarding the inconsistencies of R1, R2, and R3s medication and the Administrator stated that facility staff, including himself will be trained on medications. At 12:10 p.m., the LPA toured the physical plant areas inside and outside, with Administrator to ensure there are no health and safety hazards. Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8 and California Health and Safety Code the following deficiency was cited (refer to LIC 809-D) Exit interview conducted. A copy of the report and appeal rights were provided.