Non-compliance follow-up·April 22, 2024

At approximately 9:10AM, Licensing Program Analysts (LPAs) Florio and Felias arrived unannounced to conduct a Case Management - Legal/Non-compliance visit and met with Administrator/Executive Director, Susan Edwards. Facility serves residents with dementia and has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance and capacity for 70 non-ambulatory and bedridden residents. Of the 70 residents, 20 residents can be bedridden. Facility has an approved hospice waiver for 16 individuals. LPAs requested and reviewed documents for all employees hired from January 2024 to April 2024. Review of documents showed that facility hired 2 individuals during this time frame and has either conducted training or have scheduled training for them in the following areas: Reporting Requirements Personal Rights Incidental, Medical, and Dental Care Welfare and Institutions Code Administrator and Designated Representatives. LPAs conducted a walkthrough with Executive Director. During walkthrough, LPAs observed that a medication cart was unattended and unlocked. LPAs observed that routine and narcotic medications were on top of the unlocked cart. LPAs notified the medication technician on duty who immediately put the medications away and locked the cart (this deficiency has been cited, see LIC809-D, Regulation 87705(f)(2)). Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. **An Immediate Civil Penalty in the total amount of $1,000 is being assessed for a repeat violation of Regulation 87705(f)(2) for a third or subsequent cited violation within 12 months of the last violation . (See LIC421IM)** Exit interview conducted. Copy of report, LIC809D, LIC421IM, Plan of Corrections, and Appeal Rights discussed and provided to Executive Director. Signature on form confirms receipt of documents.