Follow-up·February 8, 2024

At approximately 11:15AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Other Visit and met with Regional Health and Wellness Director, Roschelle Factor, and Regional Operations Specialist, Sahar Mosalla . The purpose of today's visit is to follow up on self-reported incidents that were submitted to Community Care Licensing (CCL). Incident Report 1: CCL received an incident report on 01/29/2024. Report stated that on 01/21/2024, three medications were found in a medication cup in Resident 1's (R1) bedroom. Facility conducted an in-service training for all medication technicians. Facility made all appropriate notifications per regulation. Incident Report 2: CCL received an incident report on 02/02/2024. Report stated that on 01/23/2024, Resident 2 (R2) was given an extra dose of medication at the request of R2's Responsible Party. Facility conducted an in-service training for all medication technicians. Facility made all appropriate notifications per regulation. Incident Report 3: CCL received an incident report on 02/02/2024. Report stated that on 01/27/2024, Resident 3 (R3) was given an extra dose of medication. Report stated that R3 was given half a tablet of medication by Staff Member 1 (S1), and then was given one full tablet of medication by Staff Member 2 (S2). Facility conducted an in-service training for all medication technicians. Facility made all appropriate notifications per regulation. LPA also requested for updated Administrator Paperwork. During visit, LPA was informed that Facility has a new Executive Director, Sam Faye. LPA requested for the following documents to be submitted to the Regional Office so they can be processed as the new Administrator. Administrator Documents to be submitted to CCL by 02/18/2024. Continued on LIC809C Continued from LIC809 Administrator Documents · LIC 308 (Designation of Facility Responsibility) · Active and Current Administrator Certificate · First Aid Certificate · Administrator Resume · LIC 500 (Personnel Report) · LIC 501 (Personnel Record) · LIC 503 (Health Screening Report - personnel) · Proof of TB test · LIC 9182 (Criminal Record Exemption Transfer Request) · LIC 508 (Criminal Record Statement) · Copy of Driver's License or Passport that is not expired · Copy of Board of Directors' Resolution meeting minutes signed (required for all corporations) Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Facility conducted a in-service training covering Medication Management and Narcotics and Controlled Substances on 01/25/2024. LPA was provided with a copy of training documentation and cleared the deficiency cited today, 02/08/2024 during visit. Exit interview conducted. Plan of Corrections reviewed and developed with Regional Health and Wellness Director and Regional Operations Specialist. Copy of report, LIC9099D, Plan of Corrections, and Appeal Rights discussed and provided to Regional Health and Wellness Director and Regional Operations Specialist. Signature on form confirms receipt of documents.