Follow-up·April 3, 2024

Licensing Program Analyst (LPA), Shannan Hansen conducted an unannounced Case Management inspection of the facility for the purpose of following up on an Order of Immediate Exclusion letter issued on February 8, 2024. Also to follow up on three self reported incident reports submitted to Community Care Licensing (CCL). LPA met with Rabah Sbaitan, General Manager. During the Case Management inspection, General Manager Rabah Sbaitan confirmed Excluded Staff Member is no longer working in the facility or residing in the facility. LPA obtained a copy of the Resident Roster, LIC 500 and the staff schedule. In addition, LPA and General Manager toured the facility. Excluded Staff Member was not seen on the premises. Based on evidence obtained during today’s Case Management Inspection, the LPA has verified Excluded Staff Member is not present, employed, or residing at the facility. Verification of removal is complete. LPA also followed up on 2 medication errors that were self-reported to community care licensing on 3/6/2024 & 3/11/2024. On 3/1/2024 it was noted by staff (S1) Resident (R1) had been given a double dosage of medication on 2/27/2024 new bubble pack opened 2/28/2024 given out of a second bubble pack. No adverse effected noted and all required parties notified. Conversation with Health Services Director (HSD) indicated facility has made changes to medication entering policies to prevent future medication errors. LPA obtained additional information regarding a medication error that occurred on 3/1/2024 when staff observing R2 holding medications in mouth noticed previous days 6 medications in medicine cup, to have been taken later on the previous day. No adverse effects observed, all required parties notified. LPA obtained in service training's, disciplinary actions for staff & investigations. Continue on LIC809-C On 6/15/2023 LPA conducted a case management and cited facility for medication errors following regulation 87465(a)(5) and again on 2/12/2024 LPA conducted a case management of facility and cited for multiple self-reported medication errors and assessed civil penalties to facility for repeat violations in less then 12 months for same regulation. LPA is issuing a citation today for medication errors and Civil Penalties for a 3 rd repeat violation in less then 12 months. Citation issued during visit. ****Civil Penalties are being assessed in the amount of $250 due to a second repeat citation issued for the same section 87465(a)(5) Incidental Medical and Dental Care Services. in less than 12 months. Deficiency last cited on 2/12/2024 & 6/15/2023. *******Total Civil Penalties being given today $250.00 Appeal of Rights Given. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided