Complaint·October 18, 2024

Based on records review, Licensee was able to provide proof of training from Relias for MT. The following topics were used for Medication training: Actions and Interactions of Common Medications; Assisting with Self-Administration of Medications: Guideline, Medication Orders, Procedure, The Basics; Medication Documentation for California; Providing Medication Assistance – California, Psychotropic Medications: Antipsychotics and Beyond. All trainings were finished through online completion on 2/5/2022. However, during the interviews of staff members (S2, S3, S4), it was found out that 3 out of 3 didn’t have a documented training with regards to medication. Therefore, based on interviews and records review and information collected, the above allegations are determined to be SUBSTANTIATED. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Report is reviewed and a copy of this report and appeals rights is provided. page 2 of 2 During RPs interview with LPA Heberle, with regards to loose medication on the floor, it was stated that LPA asked RP if there is any evidence or photographic proof. RP stated that there is none. LPA interviewed AD1 and LPA asked for a walkthrough on how the medication pass is done. A staff member S5 walked the LPA through the process for medication. It was explained by S5 that when new medications come in, they log it in the centrally stored medication and destruction records (CSMDR). They then put in in different plastic storages that are assigned to each resident. Labeled with room number also. All medications are locked in the medication room where only staff have access too. LPA observed the medication room to be always locked, there is also a medication cart that has PRN and Narcotics stored with different keys being used. There are also 2 cabinets where routine medications for residents and overflow are stored which also has separate locks. Regarding the allegations of facility staff spoke to resident inappropriately, RP stated that a staff (S1), called a resident "Boo" Totally disrespectful. S1 had no clue that was not appropriate. LPA Heberle interviewed 3 staff members. S2 stated that they only seen staff members referred to residents by name, never pet names. S3 mentioned that they have not heard any staff members speak to residents inappropriately. Staff members don't use pet names, they always address by name. Based on interviews, observations and records review, the department has determined that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Report is reviewed and copy is provided. Regarding the allegation of facility staff have not been providing training on emergency preparedness, RP stated that they are not sure that the requirement that "All employees must be trained upon hire and annually on the community's emergency preparedness plan and that all employees must participate in a quarterly emergency preparedness drill is happening. The owner said only 2 employees have to do this. Based on records review, there is a log of training for emergency preparedness dating back 12/21/2021, 3/8/2022, 7/28/2022, 10/10/2022, 12/20/2022, 3/4/2023, 6/20/2023, 9/9/2023 & 12/20/2023. All are signed by staff members present during training and topics covered are fire and earthquake drills. Based on interviews, the department has determined that that the allegations were false, could not have happened and/or is without a reasonable basis, therefore the allegations are UNFOUNDED. Report is reviewed and copy is provided.