Routine inspection (multi-day)·January 18, 2024

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to continue the required Annual inspection and was greeted by Morgan Holien, Executive Director (ED). Facility currently has one resident on hospice. During initial annual inspection on 1/11/2024, LPA initiated file review at 3:00pm. LPA reviewed 5 resident files. Per LPA interview with ED and HWD, one resident is currently on hospice. Per LPA interview with HWD, facility does not have hospice care plan for R1. Per Title 22 regulation 87633(a)(4) Hospice Care of Terminally Ill Residents (a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility when all of the following conditions are met:(4) A written hospice care plan which specifies the care, services, and necessary medical intervention related to the terminal illness as necessary to supplement the care and supervision provided by the facility is developed ...prior to the initiation of hospice services in the facility for that resident, and all hospice care plans are fully implemented by the licensee and by the hospice(s) ( deficiency cited, see 809D ). During initial annual inspection on 1/11/2024, LPA reviewed resident files at 3:30pm. LIC602 for R4 shows a DX of dementia; however, it has not been updated since 2021. Per Title 22 regulation 87705(c)(5) Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs ( deficiency cited, see 809D ). Additionally, the facility does not currently retain residents with DX of dementia. Per Title 22 regulation 87455(c)(3)(B) Acceptance and Retention Limitations (c) No resident shall be accepted or retained if any of the following apply: (3) The resident's primary need for care and supervision results from…: B) Dementia, unless the requirements of Section 87705, Care of Persons with Dementia, are met ( deficiency cited, see 809D ). Note: 809D final printed on 1/11/2024 amended to capture signature. Continued on 809C... Continued from 809... During initial annual inspection on 1/11/2024, at approximately 1:00pm, LPA observed medications to be centrally stored in a locked room in the assisted living building. Per LPA interview with Director of Health and Wellness (DHW) and Med Tech (S1) facility currently using an e-mar, maintaining Centrally Stored Medication Logs, and pre-pouring medications. LPA advised DHW per Title 22 regulation 87465(h)(5) Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers ( deficiency cited, see 809D ). LPA and S1 conducted spot check of medications. LPA and S1 reviewed medications for resident R2. LPA and S1 observed resident R2 to have 2 missed doses of Acetaminophen 325mg, Amlodipine 2.5 mg, and Furosemide 20 mg. Doses present in bubble packs, but documented as given to R2. LPA and S1 reviewed missed doses with DHW. LPA advised DHW per Title 22 regulation 87465(a)(4) Incidental Medical and Dental Care - The licensee shall assist residents with self-administered medications as needed ( deficiency cited, see 809D ). On 1/18/2024 at approximately 9:30am LPA reviewed staff files. Five [5] out of five [5] staff files either were missing the training log entirely, or the training log present did not show the number of training hours completed. Per Title 22 regulation 87412(c) Personnel Records (c) Licensees shall maintain in the personnel records verification of required staff training and orientation (2) Documentation of staff training shall include (D) Number of training hours per subject ( deficiency cited, see 809D ). Civil Penalty in the amount of $600 is being assessed for failure to correct deficiency 87405(a) cited on 1/11/2024 with plan of correction due date of 1/12/2024. CCL may assess $100 per day until deficiency is cleared and plan of correction is satisfied. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: Evidence of Liability Insurance and Plan of Operation. Continued on 809C(2)... Continued from 809C... Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with ED. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with ED and a copy of this report was given.