Follow-up on corrections·August 29, 2024

This unannounced Case Management – Deficiencies inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of issuing citations for deficiencies observed during the investigation into Complaint Control No. 22-AS-20201221092131. LPA met with Administrator (AD) Allen Nishikawa and explained the reason for today’s inspection. During the course of the investigation, LPA inspected the facility, interviewed AD, Chief Operating Officer (COO) Faye Shen, residents, and staff, and obtained and reviewed copies of the resident roster, staff roster, Resident #1’s (R1) Resident File, and Medication Administration Records (MAR) for multiple residents. When interviewed, R1 stated that they had previously received the wrong medications which caused a severe reaction, so they double-check the medications they receive from the medication technician. Regarding the alleged past medication error, R1 did not specify if it occurred at this facility or another location. LPA reviewed R1’s Resident File and interviewed the staff in charge of medications and did not obtain information corroborating a medication error. LPA reviewed the MAR for R1 and noted dozens of instances of medications not being signed off as being given to R1 with no documented explanation, although LPA obtained no evidence of R1 suffering a severe reaction. The MAR for four other residents also showed similar blanks where the medications were not signed off, but the pills were no longer in the bubble packs. Per the staff in charge of medications, the reason the doses were not signed off by the medication technician is because the medication technician forgot or did not have time to sign off on the dose and this does not indicate that the medications were not given. However, the doses were still not properly documented as required to ensure residents were receiving their medications as required. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.